Provider Demographics
NPI:1083188304
Name:GARDNER, SUSAN M (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 LIBBIE MILL EAST BLVD APT 231
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-2132
Mailing Address - Country:US
Mailing Address - Phone:917-488-3374
Mailing Address - Fax:
Practice Address - Street 1:313 E BROAD ST STE 125
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1737
Practice Address - Country:US
Practice Address - Phone:044-045-3588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040108211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical