Provider Demographics
NPI:1073663191
Name:GARDNER, ELLEN PATRICIA (PT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:PATRICIA
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 MAUREEN DR
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02917-2336
Mailing Address - Country:US
Mailing Address - Phone:401-349-2205
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-5418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI1222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist