Provider Demographics
NPI:1386301885
Name:GARDNER, HAYLEY
Entity type:Individual
Prefix:
First Name:HAYLEY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
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 698
Mailing Address - Street 2:
Mailing Address - City:EATONVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98328-0698
Mailing Address - Country:US
Mailing Address - Phone:360-879-1000
Mailing Address - Fax:
Practice Address - Street 1:209 LYNCH CREEK RD E
Practice Address - Street 2:
Practice Address - City:EATONVILLE
Practice Address - State:WA
Practice Address - Zip Code:98328
Practice Address - Country:US
Practice Address - Phone:360-879-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASI61222035235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA578189COtherWASHINGTON OSPI
WASI61222035OtherWASHINGTON DEPARTMENT OF HEALTH