Provider Demographics
NPI:1598282188
Name:GARDNER-YOUNG, ANDREA R (LPC, CMHC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:GARDNER-YOUNG
Suffix:
Gender:F
Credentials:LPC, CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2416
Mailing Address - Country:US
Mailing Address - Phone:801-259-1350
Mailing Address - Fax:
Practice Address - Street 1:1995 NEWMARK AVE # 1017
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-4727
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7403966-6004101YM0800X
ORC5086101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health