Provider Demographics
NPI:1669506846
Name:GARDENIER, HOLLY JANE (MS, LPC, CSAC, ICS)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JANE
Last Name:GARDENIER
Suffix:
Gender:F
Credentials:MS, LPC, CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 E CLOVERNOOK LN
Mailing Address - Street 2:
Mailing Address - City:FOX POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4217
Mailing Address - Country:US
Mailing Address - Phone:414-881-8097
Mailing Address - Fax:262-375-1071
Practice Address - Street 1:W62N248 WASHINGTON AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2768
Practice Address - Country:US
Practice Address - Phone:414-545-1950
Practice Address - Fax:262-375-1071
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14743133101Y00000X
WI4187-125101YP2500X
WI15306-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42025100Medicaid