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General NPI Number Information
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NPI Number | 1205631066
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Entity Type | Individual
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Provider Name | LISA MICHELLE GARDNER
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Gender | Female
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Dates
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Enumeration Date | 02/17/2025
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Last Update Date | 02/17/2025
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Provider Practice Location Address
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Address Line | 156 SULLIVAN TRL
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City | LA VERGNE
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State | TN
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Zip | 37086-3027
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Country | US
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Telephone | 618-514-5687
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Fax |
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Provider Business Mailing Address
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Address Line | 111 STONE HOLLOW DR
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City | MANCHESTER
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State | TN
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Zip | 37355-3411
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Country | US
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Telephone | 618-514-5687
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | RBT-24-397993
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License Number State | TN
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