Provider Demographics
NPI:1275000861
Name:GARDNER, KAILEE MISHELLE
Entity Type:Individual
Prefix:
First Name:KAILEE
Middle Name:MISHELLE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 1/2 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1619
Mailing Address - Country:US
Mailing Address - Phone:740-412-8673
Mailing Address - Fax:
Practice Address - Street 1:101 1/2 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1619
Practice Address - Country:US
Practice Address - Phone:740-420-9490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.168400101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)