Provider Demographics
NPI:1215567128
Name:GARDNER, KAITLYN (LPC)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 S 51ST CT STE G
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3666
Mailing Address - Country:US
Mailing Address - Phone:479-323-2424
Mailing Address - Fax:
Practice Address - Street 1:3111 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5017
Practice Address - Country:US
Practice Address - Phone:479-452-6650
Practice Address - Fax:479-452-5847
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2001192101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health