Basic Information
| Provider Information | |||||||||
| NPI: | 1013945229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | LAMAURICE | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22250 PROVIDENCE DR | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135761000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22250 PROVIDENCE DR | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135761000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301007265 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 680F34976 | 01 | MI | BLUE CROSS MICHIGAN | OTHER |