Provider Demographics
NPI:1871718502
Name:GARDNER, RISA ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:RISA
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3314 HENDERSON BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2998
Mailing Address - Country:US
Mailing Address - Phone:813-877-5400
Mailing Address - Fax:813-877-0661
Practice Address - Street 1:3314 HENDERSON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2998
Practice Address - Country:US
Practice Address - Phone:813-877-5400
Practice Address - Fax:813-877-0661
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4383103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73976Medicare ID - Type UnspecifiedPSYCHOLOGIST