Provider Demographics
NPI:1497266001
Name:GARDNER, MICHAEL K (LCDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7515 GREENVILLE AVE STE 1000
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-3852
Mailing Address - Country:US
Mailing Address - Phone:469-480-5560
Mailing Address - Fax:
Practice Address - Street 1:7515 GREENVILLE AVE STE 1000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-3852
Practice Address - Country:US
Practice Address - Phone:469-480-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4871101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)