Provider Demographics
NPI:1821546227
Name:GARDNER, NICHOLE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 YONDERVIEW RD
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12529-5051
Mailing Address - Country:US
Mailing Address - Phone:518-567-5310
Mailing Address - Fax:
Practice Address - Street 1:60 COTTAGE ST
Practice Address - Street 2:
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1302
Practice Address - Country:US
Practice Address - Phone:413-629-1021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA126126101YM0800X
NY090572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health