Provider Demographics
NPI:1184383002
Name:GARDINER, MADELINE V (LPC)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:V
Last Name:GARDINER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:
Other - Last Name:GARDINER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:30107 SAW GRASS TRL
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1139
Mailing Address - Country:US
Mailing Address - Phone:512-762-3573
Mailing Address - Fax:
Practice Address - Street 1:4118 WILLIAMS DR STE 101
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-1335
Practice Address - Country:US
Practice Address - Phone:512-762-3573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82275101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional