Basic Information
| Provider Information | |||||||||
| NPI: | 1760759054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, CADC I | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GARDNER | ||||||||
| OtherFirstName: | CHRISTOPHER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MA, CADC I | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 82819 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972820819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032335405 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1027 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032398400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2011 | ||||||||
| LastUpdateDate: | 05/21/2019 | ||||||||
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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 | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.