Healthcare Provider Details

I. General information

NPI: 1992417570
Provider Name (Legal Business Name): KRISTIN KAY GARDNER CASAC-T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 12/15/2022
Certification Date: 12/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 COMMUNITY LN
LIBERTY NY
12754-2851
US

IV. Provider business mailing address

2875 ROUTE 35
KATONAH NY
10536-3181
US

V. Phone/Fax

Practice location:
  • Phone: 845-867-4304
  • Fax:
Mailing address:
  • Phone: 914-666-0191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number231012342
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: