Basic Information
| Provider Information | |||||||||
| NPI: | 1720646243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | KATELYN | ||||||||
| MiddleName: | MARIE-FERNANDEZ | ||||||||
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| Credential: | TLLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13101 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857704 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1777 AXTELL DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480844400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486135377 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2019 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 14478193 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.