Provider Demographics
NPI:1801502711
Name:GARDNER, STACEY LYNN (ALC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MILL WALK CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-1545
Mailing Address - Country:US
Mailing Address - Phone:412-287-7088
Mailing Address - Fax:
Practice Address - Street 1:401 HUGHES RD STE 2
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1144
Practice Address - Country:US
Practice Address - Phone:412-287-7088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04091101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health