Healthcare Provider Details

I. General information

NPI: 1912217290
Provider Name (Legal Business Name): LAURA LEIGH GARDNER MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 STALLSVILLE RD
SUMMERVILLE SC
29485-4934
US

IV. Provider business mailing address

141 SPRING MEADOWS DR
SUMMERVILLE SC
29485-8792
US

V. Phone/Fax

Practice location:
  • Phone: 843-832-1795
  • Fax:
Mailing address:
  • Phone: 843-851-9084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4765
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: