Provider Demographics
NPI:1992162408
Name:GARDNER, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
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 1:527 MEADOW LILY DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-8355
Mailing Address - Country:US
Mailing Address - Phone:815-715-6916
Mailing Address - Fax:
Practice Address - Street 1:212 BARNEY DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5271
Practice Address - Country:US
Practice Address - Phone:815-927-5466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0197341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical