MEDICARE: KANIA ANTIONE GARDNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1518453141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KANIA ANTIONE GARDNER

Provider Business Mailing Address
First Line	:	4460 S. HIGHLAND DR
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84124-3503
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4460 S. HIGHLAND DR
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84124-3503
Country	:	US
Telephone Number	:	801-537-7537
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2018
Last Update Date	:	07/06/2018

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Directions to “ KANIA ANTIONE GARDNER ” Practice Location

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