Provider Demographics
NPI:1912790916
Name:GARDNER, AVERY MCCOY
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:MCCOY
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 WEST ST APT A
Mailing Address - Street 2:
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404-1775
Mailing Address - Country:US
Mailing Address - Phone:609-661-2423
Mailing Address - Fax:
Practice Address - Street 1:1233 SHELBURNE RD STE 203
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7733
Practice Address - Country:US
Practice Address - Phone:802-391-0704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2406382101YM0800X
VT097.0136418101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health