Provider Demographics
NPI:1679996326
Name:GARDNER, MARILYN
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 MIRAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3301
Mailing Address - Country:US
Mailing Address - Phone:216-320-5022
Mailing Address - Fax:
Practice Address - Street 1:2155 MIRAMAR BLVD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-3301
Practice Address - Country:US
Practice Address - Phone:216-320-5022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-3646235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist