Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor |
NPI | 1003076498 |
---|---|
Provider Name | Mr. Philip D Gardner JR. |
First Address | Ithaca, NY 14850-4333 |
Second Address | Ithaca, NY 14850-4333 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2008 |
Last Update Date | 10/06/2008 |