Basic Information
| Provider Information | |||||||||
| NPI: | 1497752117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDZINA | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 474 | ||||||||
| Address2: | |||||||||
| City: | ANGLETON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775160474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9794803327 | ||||||||
| FaxNumber: | 9798480259 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 W MULBERRY ST | ||||||||
| Address2: | |||||||||
| City: | ANGLETON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775155504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9794803327 | ||||||||
| FaxNumber: | 9798480259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 7657 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.