Provider Demographics
NPI:1306910948
Name:GARDNER, RONALD D (PSYD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:D
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97528-0012
Mailing Address - Country:US
Mailing Address - Phone:541-592-4111
Mailing Address - Fax:541-592-3916
Practice Address - Street 1:25647 REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:CAVE JUNCTION
Practice Address - State:OR
Practice Address - Zip Code:97531-9724
Practice Address - Country:US
Practice Address - Phone:541-592-4111
Practice Address - Fax:541-592-3916
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1372103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR127725Medicaid
ORR63504Medicare UPIN
OR112651Medicare ID - Type Unspecified