Provider Demographics
NPI:1104855774
Name:GARDNER, VIKKI R (LPCC-S)
Entity Type:Individual
Prefix:
First Name:VIKKI
Middle Name:R
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:VIKKI
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PCC
Mailing Address - Street 1:5807 HAMPSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-3206
Mailing Address - Country:US
Mailing Address - Phone:419-450-2170
Mailing Address - Fax:419-406-4590
Practice Address - Street 1:3950 SUNFOREST CT FL 2
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4485
Practice Address - Country:US
Practice Address - Phone:419-450-2170
Practice Address - Fax:419-406-4590
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE3755101Y00000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401007972OtherSTATE OF MICHIGAN - DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS