Provider Demographics
NPI:1013666411
Name:GARDNER, NICHELSEA (LCDC)
Entity Type:Individual
Prefix:
First Name:NICHELSEA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:NICHELSEA
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCDC
Mailing Address - Street 1:1732 KATYLAND DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77493-1751
Mailing Address - Country:US
Mailing Address - Phone:281-237-6384
Mailing Address - Fax:
Practice Address - Street 1:1732 KATYLAND DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77493-1751
Practice Address - Country:US
Practice Address - Phone:281-237-6384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13674101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)