Provider Demographics
NPI:1578112124
Name:GARDNER, ERIN KELLE (LLPC, CAADC)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:KELLE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LLPC, CAADC
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:KELLE
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1012 WARBLER LN
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-9545
Mailing Address - Country:US
Mailing Address - Phone:231-357-1274
Mailing Address - Fax:
Practice Address - Street 1:520 COBB ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2588
Practice Address - Country:US
Practice Address - Phone:231-775-6521
Practice Address - Fax:231-775-1366
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401018598101YP2500X
MI6401016271101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health