Provider Demographics
NPI:1184299059
Name:GARDNER, CAROLIN (LMFT, LPCC)
Entity type:Individual
Prefix:
First Name:CAROLIN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:
Credentials:LMFT, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1682
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-1682
Mailing Address - Country:US
Mailing Address - Phone:951-818-8061
Mailing Address - Fax:
Practice Address - Street 1:110 BLUE RAVINE RD STE 104
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-4712
Practice Address - Country:US
Practice Address - Phone:916-899-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15845101Y00000X
CA138939106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor