Healthcare Provider Details

I. General information

NPI: 1306750419
Provider Name (Legal Business Name): CORY GARDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3353 BRUNER AVE
BRONX NY
10469-2725
US

IV. Provider business mailing address

3353 BRUNER AVE
BRONX NY
10469-2725
US

V. Phone/Fax

Practice location:
  • Phone: 646-341-7179
  • Fax:
Mailing address:
  • Phone: 646-341-7179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: