Provider Demographics
NPI:1477316503
Name:GARDNER, CASSANDRA JO (TRS/CTRS)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:JO
Last Name:GARDNER
Suffix:
Gender:F
Credentials:TRS/CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4558 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4104
Mailing Address - Country:US
Mailing Address - Phone:435-823-3402
Mailing Address - Fax:
Practice Address - Street 1:4558 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4104
Practice Address - Country:US
Practice Address - Phone:435-823-3402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11392749-4002225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist