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
State | License ID | Taxonomies |
---|---|---|
NM | 445 | 225100000X, 2251E1200X, 2251H1200X, 2251H1300X, 2251N0400X, 2251P0200X, 2251S0007X, 2251X0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | |
No | 2251E1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Ergonomics |
No | 2251H1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand |
No | 2251H1300X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Human Factors |
No | 2251N0400X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology |
No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
No | 2251S0007X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
No | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NM | 850448868 | Other | ALL OTHER INSURANCIES |
NM | 201079804 | Other | PRESBYTERIAN HEALTH PLAN |
NM | 00074136 | Medicaid | |
NM | NM00Q036 | Other | BLUECROSSBLUESHIELDS |