Provider Demographics
NPI:1477825446
Name:GARDNER, TESIA (LCSW)
Entity Type:Individual
Prefix:
First Name:TESIA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 KENTLAND DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-2416
Mailing Address - Country:US
Mailing Address - Phone:540-314-3779
Mailing Address - Fax:
Practice Address - Street 1:3704 KENTLAND DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-2416
Practice Address - Country:US
Practice Address - Phone:540-314-3779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040077201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical