Healthcare Provider Details

I. General information

NPI: 1699895219
Provider Name (Legal Business Name): MRS. DIANE GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 BLUE JAY DR
LIBERTY MO
64068-1977
US

IV. Provider business mailing address

2609 GLENN HENDREN DR
LIBERTY MO
64068-1738
US

V. Phone/Fax

Practice location:
  • Phone: 816-407-2315
  • Fax: 816-407-1555
Mailing address:
  • Phone: 816-407-4555
  • Fax: 816-781-6973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number01461
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: