Provider Demographics
NPI:1861550402
Name:GARDNER, KATHRYN D (LCPC)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:D
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MS
Other - First Name:KATHRYN
Other - Middle Name:D
Other - Last Name:MICHALSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:10806 S DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10661 S ROBERTS RD STE 207
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-1988
Practice Address - Country:US
Practice Address - Phone:773-445-1976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.005469101YP2500X
IL180005469101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty