Healthcare Provider Details

I. General information

NPI: 1659531028
Provider Name (Legal Business Name): CONNIE C GARDNER LPC, LSATP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 MAPLE VALLEY RD
TAPPAHANNOCK VA
22560-5662
US

IV. Provider business mailing address

218 MAPLE VALLEY RD
TAPPAHANNOCK VA
22560-5662
US

V. Phone/Fax

Practice location:
  • Phone: 434-390-3512
  • Fax: 804-442-7081
Mailing address:
  • Phone: 804-445-8020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2665
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0701004280
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: