Healthcare Provider Details

I. General information

NPI: 1518319946
Provider Name (Legal Business Name): ALISA GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2016
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 AIRWAY AVE T2
COSTA MESA CA
92626-4607
US

IV. Provider business mailing address

4546 EL CAMINO REAL STE B7
LOS ALTOS CA
94022-1069
US

V. Phone/Fax

Practice location:
  • Phone: 949-438-2342
  • Fax:
Mailing address:
  • Phone: 866-362-4246
  • Fax: 650-260-6030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW18615
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: