Healthcare Provider Details

I. General information

NPI: 1710824404
Provider Name (Legal Business Name): RAYMOND J GARDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RAY J GARDNER

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WHITNEY AVE
VALLEJO CA
94589-2194
US

IV. Provider business mailing address

2411 HANSON DR
FAIRFIELD CA
94533-8838
US

V. Phone/Fax

Practice location:
  • Phone: 707-652-3142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: