MEDICARE: MRS. TIESHA DENICE GARDNER LPC

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	101YP2500X	Professional Counselor	85009	TX

General Provider Information

NPI Number	:	1912772575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIESHA DENICE GARDNER LPC

Provider Business Mailing Address
First Line	:	8637 FAWN HILL CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-5366
Country	:	US
Telephone Number	:	281-798-4241
Fax Number	:

Provider Business Practice Location Address
First Line	:	8637 FAWN HILL CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-5366
Country	:	US
Telephone Number	:	281-798-4241
Fax Number	:

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

Provider Enumeration Date	:	11/22/2023
Last Update Date	:	11/22/2023

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