Healthcare Provider Details

I. General information

NPI: 1669383543
Provider Name (Legal Business Name): KHADAJA GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15415 ELM LEAF PL
CYPRESS TX
77429-5228
US

IV. Provider business mailing address

15415 ELM LEAF PL
CYPRESS TX
77429-5228
US

V. Phone/Fax

Practice location:
  • Phone: 256-996-0137
  • Fax:
Mailing address:
  • Phone: 256-996-0137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number96716
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: