Provider Demographics
NPI:1275998767
Name:CARMELLA GARDNER
Entity Type:Organization
Organization Name:CARMELLA GARDNER
Other - Org Name:SOUTHSIDE COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMELLA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-292-2497
Mailing Address - Street 1:3681 CAROL ANN LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7394
Mailing Address - Country:US
Mailing Address - Phone:904-292-2407
Mailing Address - Fax:904-292-2409
Practice Address - Street 1:2950 HALCYON LN
Practice Address - Street 2:SUITE 701
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-6689
Practice Address - Country:US
Practice Address - Phone:904-292-2407
Practice Address - Fax:904-292-2409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-28
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8370251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health