Healthcare Provider Details

I. General information

NPI: 1073288569
Provider Name (Legal Business Name): MARY KATHERINE GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10311 W MARKHAM ST
LITTLE ROCK AR
72205-2135
US

IV. Provider business mailing address

2809 FOREST HOME RD
JONESBORO AR
72401-5320
US

V. Phone/Fax

Practice location:
  • Phone: 501-781-2230
  • Fax:
Mailing address:
  • Phone: 866-972-1268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2404010
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: