Healthcare Provider Details

I. General information

NPI: 1962951004
Provider Name (Legal Business Name): SEAN GARDNER LPC, MS, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 W WESTERN AVE
AVONDALE AZ
85323-1848
US

IV. Provider business mailing address

3101 N CENTRAL AVE STE 550
PHOENIX AZ
85012-2635
US

V. Phone/Fax

Practice location:
  • Phone: 602-230-7373
  • Fax: 602-230-3086
Mailing address:
  • Phone: 602-230-7373
  • Fax: 602-682-7455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-19450
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC-613
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: