Provider Demographics
NPI:1336622208
Name:GARDNER, NICHELLE (LCPCC, CADC)
Entity Type:Individual
Prefix:
First Name:NICHELLE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LCPCC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 RAYMOND HILL RD
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:ME
Mailing Address - Zip Code:04071-6148
Mailing Address - Country:US
Mailing Address - Phone:207-671-7804
Mailing Address - Fax:
Practice Address - Street 1:79 MAIN ST.
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-671-7804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC6395101YA0400X
MEXL5127101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health