Provider Demographics
NPI:1609558634
Name:SUTANA GARDNER, DANNI VIENGSAVAHN
Entity type:Individual
Prefix:
First Name:DANNI
Middle Name:VIENGSAVAHN
Last Name:SUTANA GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANNI
Other - Middle Name:VIENGSAVAHN
Other - Last Name:SUTANA GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2355 STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4541
Mailing Address - Country:US
Mailing Address - Phone:808-437-0581
Mailing Address - Fax:
Practice Address - Street 1:15-2734 AHOLEHOLE ST
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-9609
Practice Address - Country:US
Practice Address - Phone:808-437-0581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2024-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR10253106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist