Provider Demographics
NPI:1184126500
Name:GARDNER, MEGAN W (MS, SSP, LPES)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:W
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MS, SSP, LPES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2436 RAYFIELD BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29709-6167
Mailing Address - Country:US
Mailing Address - Phone:843-680-4111
Mailing Address - Fax:
Practice Address - Street 1:718 S 4TH ST
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-5724
Practice Address - Country:US
Practice Address - Phone:843-917-0495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4687103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool