Provider Demographics
NPI:1497773774
Name:GARDNER, MICHAEL LEE (LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEE
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6017 REEF POINT LN
Mailing Address - Street 2:SUITE 115
Mailing Address - City:LAKE WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-7004
Mailing Address - Country:US
Mailing Address - Phone:817-915-4276
Mailing Address - Fax:
Practice Address - Street 1:4921 ROYAL DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-8827
Practice Address - Country:US
Practice Address - Phone:817-377-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19711101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional