Basic Information
| Provider Information | |||||||||
| NPI: | 1669082665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | MAGGIE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 HALLMARK DR | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082405539 | ||||||||
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| Practice Location | |||||||||
| Address1: | 444 HOSPITAL WAY STE 477 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082337832 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2020 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC-7777 | ID | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.