Provider Demographics
NPI:1114272929
Name:GARDNER, MELANIE (LPC, ATR-BC, CTS)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LPC, ATR-BC, CTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3144
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-3144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:224 N MAIN ST
Practice Address - Street 2:SUITE 217
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2720
Practice Address - Country:US
Practice Address - Phone:804-892-9262
Practice Address - Fax:804-732-8233
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005249101YP2500X
NC08-136221700000X
VA08-136221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1114272929Medicaid