Basic Information
| Provider Information | |||||||||
| NPI: | 1689866394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDINER | ||||||||
| FirstName: | MYRTHO | ||||||||
| MiddleName: | WAYLON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 W 125TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100274516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126867500 | ||||||||
| FaxNumber: | 2128285272 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 W 125TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100274516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126867500 | ||||||||
| FaxNumber: | 2128285272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 10/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.