Provider Demographics
NPI:1659531028
Name:GARDNER, CONNIE C (LPC, LSATP)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:C
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LPC, LSATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 MAPLE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:TAPPAHANNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22560-5662
Mailing Address - Country:US
Mailing Address - Phone:804-445-8020
Mailing Address - Fax:
Practice Address - Street 1:218 MAPLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-5662
Practice Address - Country:US
Practice Address - Phone:434-390-3512
Practice Address - Fax:804-442-7081
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2665251S00000X
VA0701004280261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health