Doctor Name: | ELYSE GARDNER |
NPI Number: | 1306207949 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | MS |
License Number: | 2921 |
Business Practice Address: | 6482 State Road 19 Waunakee, WI - 535979627 |
Business Phone Number: | 7155512595 |
Business Fax Number: | |
Mailing Address: | 6482 State Road 19, WAUNAKEE |
State: | WI |
Postal Code: | 535979627 |
Phone Number: | 7155512595 |
Fax Number: | |
NPI Enumeration Date: | 03/09/2016 |
NPI Last Update Date: | 03/09/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YP2500X |
License Number: | 2921 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WI |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Professional |
Taxonomy Definition: |