Provider Demographics
NPI:1235584095
Name:GARDNER, LATASHA (LPC)
Entity Type:Individual
Prefix:
First Name:LATASHA
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 1:70 CRANBERRY LN
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3503
Mailing Address - Country:US
Mailing Address - Phone:203-630-2488
Mailing Address - Fax:203-630-2499
Practice Address - Street 1:816 BROAD ST
Practice Address - Street 2:SUITE 23
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-4350
Practice Address - Country:US
Practice Address - Phone:203-630-2499
Practice Address - Fax:203-630-2499
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2820101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008062953Medicaid