Provider Demographics
NPI:1205631066
Name:GARDNER, LISA MICHELLE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 STONE HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3411
Mailing Address - Country:US
Mailing Address - Phone:618-514-5687
Mailing Address - Fax:
Practice Address - Street 1:156 SULLIVAN TRL
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-3027
Practice Address - Country:US
Practice Address - Phone:618-514-5687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-24-397993106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician