Healthcare Provider Details

I. General information

NPI: 1467653220
Provider Name (Legal Business Name): KAYLEA LYNN GARDNER B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 SE POWELL BLVD
PORTLAND OR
97202-3371
US

IV. Provider business mailing address

4004 SE 133RD AVE
PORTLAND OR
97236-3555
US

V. Phone/Fax

Practice location:
  • Phone: 503-205-4334
  • Fax:
Mailing address:
  • Phone: 503-205-4334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: