Provider Demographics
NPI:1669693735
Name:GARDNER, JAMES WILLIAM (MA, LCPC,CADC)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:WILLIAM
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MA, LCPC,CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 SCHEEL ST APT D
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-4182
Mailing Address - Country:US
Mailing Address - Phone:217-454-0192
Mailing Address - Fax:
Practice Address - Street 1:2120 SCHEEL ST APT D
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-4182
Practice Address - Country:US
Practice Address - Phone:217-454-0192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178004025101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)