Provider Demographics
NPI:1427273648
Name:GARDNER, HEATHER LYN (MA, LLP, LLPC)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:LYN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MA, LLP, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 FOUNTAIN ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3422
Mailing Address - Country:US
Mailing Address - Phone:616-456-1178
Mailing Address - Fax:616-456-1324
Practice Address - Street 1:534 FOUNTAIN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3422
Practice Address - Country:US
Practice Address - Phone:616-456-1178
Practice Address - Fax:616-456-1324
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009748101Y00000X
MI6301013130103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist