Provider Demographics
NPI:1366057994
Name:GARDNER, TAYLOR VICTORIA (EDS)
Entity type:Individual
Prefix:MRS
First Name:TAYLOR
Middle Name:VICTORIA
Last Name:GARDNER
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:VICTORIA
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS
Mailing Address - Street 1:21000 EDUCATION CT
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-5526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21000 EDUCATION CT
Practice Address - Street 2:
Practice Address - City:BROADLANDS
Practice Address - State:VA
Practice Address - Zip Code:20148-5526
Practice Address - Country:US
Practice Address - Phone:423-956-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0606849103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool