Healthcare Provider Details

I. General information

NPI: 1598772063
Provider Name (Legal Business Name): KENNETH GARY GARDNER LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 DOGWOOD DR
KOKOMO IN
46902-5737
US

IV. Provider business mailing address

2106 EASTBROOK DR
KOKOMO IN
46902-4513
US

V. Phone/Fax

Practice location:
  • Phone: 765-553-5693
  • Fax: 765-553-5772
Mailing address:
  • Phone: 765-455-4067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000566A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number80000010A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: