Provider Demographics
NPI:1770132623
Name:GARDNER, MARK EDWARD (LPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1016
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16441-1016
Mailing Address - Country:US
Mailing Address - Phone:814-882-8298
Mailing Address - Fax:
Practice Address - Street 1:101 EAST AVENUE
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507
Practice Address - Country:US
Practice Address - Phone:814-882-8298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011401101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional