Provider Demographics
NPI:1609149210
Name:GARDNER, MICHAEL TIMOTHY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TIMOTHY
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6937 SICILIA LN
Mailing Address - Street 2:
Mailing Address - City:CORRYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37721-3538
Mailing Address - Country:US
Mailing Address - Phone:865-399-4033
Mailing Address - Fax:
Practice Address - Street 1:5410 HOMBERG DR
Practice Address - Street 2:SUITE 14
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5031
Practice Address - Country:US
Practice Address - Phone:865-588-3178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000042871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNLSW0000004287OtherLICENSED CLINICAL SOCIAL WORKER