Provider Demographics
NPI:1235343542
Name:GARDNER, COLLEEN E (LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:E
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 S WHITLEY DR STE 2
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2681
Mailing Address - Country:US
Mailing Address - Phone:208-550-5063
Mailing Address - Fax:208-550-5063
Practice Address - Street 1:425 S. WHITLEY DR., SUITE #2
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83610
Practice Address - Country:US
Practice Address - Phone:208-550-5063
Practice Address - Fax:208-550-5063
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-1042101Y00000X
IDLCPC 5007101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY108969201Medicaid
WY108969203Medicaid
WY108969200Medicaid
WY108969202Medicaid