MEDICARE: AMY 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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1952761892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY GARDNER

Provider Business Mailing Address
First Line	:	7 S COVE DR
Second Line	:
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-8229
Country	:	US
Telephone Number	:	435-590-8699
Fax Number	:

Provider Business Practice Location Address
First Line	:	7 S COVE DR
Second Line	:
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-8229
Country	:	US
Telephone Number	:	435-590-8699
Fax Number	:

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

Provider Enumeration Date	:	03/04/2016
Last Update Date	:	03/04/2016

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