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General NPI Number Information
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NPI Number | 1609149210
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Entity Type | Individual
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Provider Name | MICHAEL TIMOTHY GARDNER LCSW
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Gender | Male
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Dates
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Enumeration Date | 02/13/2012
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Last Update Date | 02/13/2012
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Provider Practice Location Address
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Address Line | 5410 HOMBERG DR SUITE 14
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City | KNOXVILLE
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State | TN
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Zip | 37919-5031
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Country | US
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Telephone | 865-588-3178
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Fax |
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Provider Business Mailing Address
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Address Line | 6937 SICILIA LN
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City | CORRYTON
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State | TN
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Zip | 37721-3538
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Country | US
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Telephone | 865-399-4033
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LSW0000004287
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License Number State | TN
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