Provider Demographics
NPI:1326348533
Name:GARDNER, CAROLYN E
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:E
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 153
Mailing Address - Street 2:1076 MAIN STREET
Mailing Address - City:MALDEN ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12453-0153
Mailing Address - Country:US
Mailing Address - Phone:845-246-7834
Mailing Address - Fax:
Practice Address - Street 1:1076 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MALDEN ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12453-0153
Practice Address - Country:US
Practice Address - Phone:845-246-7834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000298-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant