Healthcare Provider Details

I. General information

NPI: 1225218860
Provider Name (Legal Business Name): MICHELE CARLA GARDNER L.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6759 N RAVENSWOOD AVE
CHICAGO IL
60626-3928
US

IV. Provider business mailing address

315 HAWTHORN AVE APT D
GLENCOE IL
60022-1624
US

V. Phone/Fax

Practice location:
  • Phone: 773-301-5257
  • Fax:
Mailing address:
  • Phone: 847-835-5637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150006366
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: