Provider Demographics
NPI:1306824164
Name:GARDNER, LORRAINE L (PT)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:L
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 1:2101 TRINITY DR
Mailing Address - Street 2:STE. N
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-4102
Mailing Address - Country:US
Mailing Address - Phone:505-661-6191
Mailing Address - Fax:505-663-0386
Practice Address - Street 1:2101 TRINITY DR
Practice Address - Street 2:STE. N
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-4102
Practice Address - Country:US
Practice Address - Phone:505-661-6191
Practice Address - Fax:505-663-0386
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM445225100000X, 2251E1200X, 2251H1200X, 2251H1300X, 2251N0400X, 2251P0200X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
No2251H1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHuman Factors
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850448868OtherALL OTHER INSURANCIES
NM201079804OtherPRESBYTERIAN HEALTH PLAN
NM00074136Medicaid
NMNM00Q036OtherBLUECROSSBLUESHIELDS