Healthcare Provider Details

I. General information

NPI: 1063912301
Provider Name (Legal Business Name): GARDENIA COVE MENTAL HEALTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6771 TAYLOR CIRCLE
MONTGOMERY AL
36117
US

IV. Provider business mailing address

6771 TAYLOR CIR
MONTGOMERY AL
36117-3417
US

V. Phone/Fax

Practice location:
  • Phone: 334-954-6010
  • Fax:
Mailing address:
  • Phone: 334-954-6010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD.34291
License Number StateAL

VIII. Authorized Official

Name: AMANDA JEAN WILLIAMS
Title or Position: OWNER, MD
Credential:
Phone: 334-954-6010