Provider Demographics
NPI:1346068376
Name:GARDNER, JUSTIN RHEA (LCDC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RHEA
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-8233
Mailing Address - Country:US
Mailing Address - Phone:214-663-1585
Mailing Address - Fax:
Practice Address - Street 1:2340 E TRINITY MILLS RD STE 300
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-1947
Practice Address - Country:US
Practice Address - Phone:972-418-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17088101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health