Provider Demographics
NPI:1073604112
Name:GARDNER, MARK STEVEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 VINCENT PL
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3615
Mailing Address - Country:US
Mailing Address - Phone:703-341-5995
Mailing Address - Fax:703-341-5995
Practice Address - Street 1:1319 VINCENT PL
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3615
Practice Address - Country:US
Practice Address - Phone:703-341-5995
Practice Address - Fax:703-341-5995
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040057961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical