Provider Demographics
NPI:1083067862
Name:GARDENHIRE, CHALENE MICHELLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CHALENE
Middle Name:MICHELLE
Last Name:GARDENHIRE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:CHALENE
Other - Middle Name:MICHELLE
Other - Last Name:LLOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1479 BROCKETT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-7326
Mailing Address - Country:US
Mailing Address - Phone:404-625-5427
Mailing Address - Fax:404-508-8944
Practice Address - Street 1:1230 PEACHTREE ST NE FL 19
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-3574
Practice Address - Country:US
Practice Address - Phone:657-400-5180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1113101041C0700X
GACSW0057651041C0700X
CSW0057651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA747634110BMedicaid
GAPE-39561Medicare PIN