Provider Demographics
NPI:1851649461
Name:GARDNER, THEODORE (PHD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PHD
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 231396
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-1396
Mailing Address - Country:US
Mailing Address - Phone:334-213-8803
Mailing Address - Fax:334-213-8815
Practice Address - Street 1:401 GOODING ST N
Practice Address - Street 2:STE 105
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6177
Practice Address - Country:US
Practice Address - Phone:208-320-7525
Practice Address - Fax:208-904-0644
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202709103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical