Provider Demographics
NPI:1891402723
Name:GARDNER, NICOLE (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12918 63RD AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6001
Mailing Address - Country:US
Mailing Address - Phone:763-210-9966
Mailing Address - Fax:763-210-6886
Practice Address - Street 1:2115 E CLAIREMONT AVE STE 2
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4761
Practice Address - Country:US
Practice Address - Phone:763-210-9966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10105-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional