Provider Demographics
NPI:1174847883
Name:GARDNER, SHAWN (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 VETERAN HILL RD
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-7265
Mailing Address - Country:US
Mailing Address - Phone:607-857-4909
Mailing Address - Fax:
Practice Address - Street 1:546 VETERAN HILL RD
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-7265
Practice Address - Country:US
Practice Address - Phone:607-857-4909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007064-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02729151Medicaid