Provider Demographics
NPI:1861026031
Name:GARDNER, DUSTIN HAYES (CG60997225 - AAC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:HAYES
Last Name:GARDNER
Suffix:
Gender:M
Credentials:CG60997225 - AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 STEELHAMMER DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4551
Mailing Address - Country:US
Mailing Address - Phone:360-623-8020
Mailing Address - Fax:360-623-1072
Practice Address - Street 1:3510 STEELHAMMER DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4551
Practice Address - Country:US
Practice Address - Phone:360-623-8020
Practice Address - Fax:360-623-1072
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60997225101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor