Provider Demographics
NPI:1649599093
Name:GARDNER, KELLEY (LMFT)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6846 POWDER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46259-7757
Mailing Address - Country:US
Mailing Address - Phone:317-727-8136
Mailing Address - Fax:
Practice Address - Street 1:720 ESKENAZI AVENUE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-880-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001701A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist