Provider Demographics
NPI:1457853160
Name:GARDNER, CHARONDA (MA , LPC)
Entity Type:Individual
Prefix:
First Name:CHARONDA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MA , 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 1027
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-8027
Mailing Address - Country:US
Mailing Address - Phone:678-831-7377
Mailing Address - Fax:678-487-5340
Practice Address - Street 1:40 MACON ST STE D
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3233
Practice Address - Country:US
Practice Address - Phone:678-831-7377
Practice Address - Fax:678-487-5340
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009546101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional