Provider Demographics
NPI:1417234170
Name:GARDNER, VENICE MAE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:VENICE
Middle Name:MAE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5914 GRANDIOSE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-4308
Mailing Address - Country:US
Mailing Address - Phone:317-257-7688
Mailing Address - Fax:
Practice Address - Street 1:5914 GRANDIOSE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46228-4308
Practice Address - Country:US
Practice Address - Phone:317-257-7688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001775A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist