Healthcare Provider Details

I. General information

NPI: 1811663644
Provider Name (Legal Business Name): SAMANTHA NICOLE GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2314 S VAL VISTA DR STE 201
GILBERT AZ
85295-5594
US

IV. Provider business mailing address

855 W SOUTHERN AVE APT 1011
MESA AZ
85210-5039
US

V. Phone/Fax

Practice location:
  • Phone: 623-263-3966
  • Fax:
Mailing address:
  • Phone: 760-900-9690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA13281
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: