Provider Demographics
NPI:1366004210
Name:GARDINER, MARIEL (LCPC)
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:GARDINER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W VAN BUREN ST STE 205
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1054
Mailing Address - Country:US
Mailing Address - Phone:847-852-0994
Mailing Address - Fax:
Practice Address - Street 1:107 W VAN BUREN ST STE 205
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1054
Practice Address - Country:US
Practice Address - Phone:312-373-0782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
180.014590101YP2500X
IL178014920101YP2500X
180014590101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional