Provider Demographics
NPI:1316368434
Name:GARDNER-WILSON, DORIS (LCSW, LCDC)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:
Last Name:GARDNER-WILSON
Suffix:
Gender:F
Credentials:LCSW, LCDC
Other - Prefix:
Other - First Name:DORIS
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, LCDC
Mailing Address - Street 1:6539 HOLLOW OAKS DR STE F
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77050-3717
Mailing Address - Country:US
Mailing Address - Phone:823-489-1998
Mailing Address - Fax:713-589-4730
Practice Address - Street 1:14825 SAINT MARYS LN STE 122
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-2989
Practice Address - Country:US
Practice Address - Phone:832-489-1998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9650101YA0400X
TX58672104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13255920OtherTEXAS DRIVERS LICENSE