Healthcare Provider Details

I. General information

NPI: 1356832497
Provider Name (Legal Business Name): COURTNEY GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 MADISON AVE
COVINGTON KY
41011-1505
US

IV. Provider business mailing address

503 FARRELL DRIVE
COVINGTON KY
41012-2680
US

V. Phone/Fax

Practice location:
  • Phone: 859-331-3292
  • Fax: 859-534-2989
Mailing address:
  • Phone: 859-578-3292
  • Fax: 859-578-3242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number255079
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: