Provider Demographics
NPI:1003242397
Name:GARDNER, ADREA L (DPT)
Entity Type:Individual
Prefix:
First Name:ADREA
Middle Name:L
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1096 S BELSAY RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1948
Mailing Address - Country:US
Mailing Address - Phone:888-218-4045
Mailing Address - Fax:810-249-4230
Practice Address - Street 1:1096 S BELSAY RD
Practice Address - Street 2:SUITE G
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1948
Practice Address - Country:US
Practice Address - Phone:888-218-4045
Practice Address - Fax:810-249-4230
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016492225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist