Provider Demographics
NPI:1275511792
Name:GARDNER, KAREN (LCSW)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 INDEPENDENCE BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2437
Mailing Address - Country:US
Mailing Address - Phone:910-796-9969
Mailing Address - Fax:910-796-0270
Practice Address - Street 1:2516 INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2437
Practice Address - Country:US
Practice Address - Phone:910-796-9969
Practice Address - Fax:910-796-0270
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0033191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD6513OtherMEDCOST
NC1205WOtherBLUE CROSS
NC6002206Medicaid