Provider Demographics
NPI:1568271617
Name:GARDNER, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 BADIOLA ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4389
Mailing Address - Country:US
Mailing Address - Phone:208-454-8389
Mailing Address - Fax:
Practice Address - Street 1:4477 W EMERALD ST
Practice Address - Street 2:SUITE C100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2058
Practice Address - Country:US
Practice Address - Phone:208-454-8389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8921970104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker