Healthcare Provider Details

I. General information

NPI: 1942534201
Provider Name (Legal Business Name): WILLIAM HENRY GARDNER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 09/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 PAN AMERICAN FWY NE
ALBUQUERQUE NM
87107-4786
US

IV. Provider business mailing address

3405 PAN AMERICAN FWY NE
ALBUQUERQUE NM
87107-4786
US

V. Phone/Fax

Practice location:
  • Phone: 505-222-0375
  • Fax: 505-222-0301
Mailing address:
  • Phone: 505-222-0375
  • Fax: 505-222-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number413
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: