MEDICARE: VIKKI R GARDNER LPCC-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	E3755	OH
2	101YP2500X	Professional Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6401007972	OTHER	MI	STATE OF MICHIGAN - DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS

General Provider Information

NPI Number	:	1104855774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIKKI R GARDNER LPCC-S

Provider Business Mailing Address
First Line	:	5807 HAMPSHIRE LN
Second Line	:
City	:	YPSILANTI
State	:	MI
Zip	:	48197-3206
Country	:	US
Telephone Number	:	419-450-2170
Fax Number	:	419-406-4590

Provider Business Practice Location Address
First Line	:	3950 SUNFOREST CT FL 2
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43623-4485
Country	:	US
Telephone Number	:	419-450-2170
Fax Number	:	419-406-4590

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	01/14/2024

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