Provider Demographics
NPI:1124857735
Name:GARDNER, ALISHA RENEE
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:RENEE
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 1:27 GARDNER RD
Mailing Address - Street 2:
Mailing Address - City:NEW WAVERLY
Mailing Address - State:TX
Mailing Address - Zip Code:77358-3948
Mailing Address - Country:US
Mailing Address - Phone:936-581-0565
Mailing Address - Fax:
Practice Address - Street 1:1305 11TH ST
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-3811
Practice Address - Country:US
Practice Address - Phone:936-642-0061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX90584101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional