Provider Demographics
NPI:1275854283
Name:GARDNER, TERRY (MSCP, LPC)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MSCP, LPC
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 372
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27285-0372
Mailing Address - Country:US
Mailing Address - Phone:336-926-4308
Mailing Address - Fax:
Practice Address - Street 1:1025 BILOXI AVE
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-9556
Practice Address - Country:US
Practice Address - Phone:336-926-4308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7227101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional