Provider Demographics
NPI:1760753768
Name:GARDNER, EMILY ANN (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 LEIF DR
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-1769
Mailing Address - Country:US
Mailing Address - Phone:360-751-6543
Mailing Address - Fax:
Practice Address - Street 1:921 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2316
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60261527101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health