Healthcare Provider Details

I. General information

NPI: 1508590654
Provider Name (Legal Business Name): ALBERT DESHAWN GARDNER LPC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 POLO RD APT 625
COLUMBIA SC
29223-4445
US

IV. Provider business mailing address

811 POLO RD APT 625
COLUMBIA SC
29223-4445
US

V. Phone/Fax

Practice location:
  • Phone: 803-459-2919
  • Fax:
Mailing address:
  • Phone: 803-459-2919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCOU.10874PCI
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: