Provider Demographics
NPI:1588023865
Name:GARDNER, EMILY (OT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2531 HAMMOCK ST UNIT 718
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-2050
Mailing Address - Country:US
Mailing Address - Phone:919-770-8995
Mailing Address - Fax:
Practice Address - Street 1:1208 NEW GARDEN RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410
Practice Address - Country:US
Practice Address - Phone:336-297-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5251225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist