Provider Demographics
NPI:1164810859
Name:GARDNER, LAURA MICHELE (MA, MFT)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MICHELE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MA, MFT
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 19099
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-0099
Mailing Address - Country:US
Mailing Address - Phone:510-594-4300
Mailing Address - Fax:510-768-5577
Practice Address - Street 1:3300 POWELL ST STE 207
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1515
Practice Address - Country:US
Practice Address - Phone:510-594-4300
Practice Address - Fax:510-768-5577
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1862106H00000X
CA53622106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist