Provider Demographics
NPI:1831751890
Name:GARDNER, TRACY O (LPC, NCC, NCSC, LSW,)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:O
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LPC, NCC, NCSC, LSW,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1620
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-1620
Mailing Address - Country:US
Mailing Address - Phone:662-396-1167
Mailing Address - Fax:
Practice Address - Street 1:401 E WALDRON ST STE B
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-4707
Practice Address - Country:US
Practice Address - Phone:662-396-1167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-30
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1283101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional