Provider Demographics
NPI:1518327816
Name:GARDINER, KRISTA (LMT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:GARDINER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-3435
Mailing Address - Country:US
Mailing Address - Phone:860-930-0056
Mailing Address - Fax:
Practice Address - Street 1:74 NEW LONDON TPKE STE 1
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4204
Practice Address - Country:US
Practice Address - Phone:860-968-0715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005568225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist