Provider Demographics
NPI:1598772063
Name:GARDNER, KENNETH GARY (LMHC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:GARY
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 EASTBROOK DR
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-4513
Mailing Address - Country:US
Mailing Address - Phone:765-455-4067
Mailing Address - Fax:
Practice Address - Street 1:1810 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-5737
Practice Address - Country:US
Practice Address - Phone:765-553-5693
Practice Address - Fax:765-553-5772
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN80000010A171100000X
IN39000566A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INGARDN-0005OtherCOMPCARE ID NUMBER
IN000000343499OtherANTHEM BX/BS ID NUMBER
IN083845-000OtherMAGELLAN ID NUMBER
IN11347555OtherCAQH ID NUMBER
IN2067371OtherCIGNA ID NUMBER