Provider Demographics
NPI:1174640593
Name:GARDNER-GLENN, CONNIE (OT,)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
Last Name:GARDNER-GLENN
Suffix:
Gender:F
Credentials:OT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 W ATWOOD ST
Mailing Address - Street 2:
Mailing Address - City:GALION
Mailing Address - State:OH
Mailing Address - Zip Code:44833-2553
Mailing Address - Country:US
Mailing Address - Phone:419-462-5085
Mailing Address - Fax:
Practice Address - Street 1:990 S PROSPECT ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6283
Practice Address - Country:US
Practice Address - Phone:740-387-2900
Practice Address - Fax:740-387-2922
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT001625225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist