Healthcare Provider Details

I. General information

NPI: 1477796225
Provider Name (Legal Business Name): RYAN GARDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 S ELM AVE
FRESNO CA
93706
US

IV. Provider business mailing address

2740 S ELM AVE
FRESNO CA
93706-5435
US

V. Phone/Fax

Practice location:
  • Phone: 559-457-5200
  • Fax: 559-457-5290
Mailing address:
  • Phone: 559-457-5200
  • Fax: 559-457-5290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW28767
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: