1235343542 NPI number — COLLEEN E GARDNER LCPC, NCC

Table of content: COLLEEN E GARDNER LCPC, NCC (NPI 1235343542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235343542 NPI number — COLLEEN E GARDNER LCPC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
COLLEEN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC, NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235343542
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 S WHITLEY DR STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRUITLAND
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83619-2681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-550-5063
Provider Business Mailing Address Fax Number:
208-550-5063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 S. WHITLEY DR., SUITE #2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-550-5063
Provider Business Practice Location Address Fax Number:
208-550-5063
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  LPC-1042 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LCPC 5007 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108969201 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 108969203 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 108969200 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 108969202 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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