Provider Demographics
NPI:1629002522
Name:GARDNER, MINDY BETH (PT)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:BETH
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:BETH
Other - Last Name:STARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2629 LARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-4319
Mailing Address - Country:US
Mailing Address - Phone:304-638-7327
Mailing Address - Fax:
Practice Address - Street 1:2629 LARWOOD DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-4319
Practice Address - Country:US
Practice Address - Phone:304-638-7327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002501225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2155066OtherUHC
WV4168111OtherDME - CIGNA
WVP00257820OtherRAILROAD MEDICARE
WV0011253000Medicaid
WV3810004659Medicaid
WV151628500OtherFEDERAL WORKERS COMP
WVCF9824OtherRR MEDICARE
WV2155066OtherUHC
WVCF9824OtherRR MEDICARE
WV9296571Medicare PIN
WV316094OtherCARELINK
WV4168111Medicare PIN
WV2155066OtherMAMSI
WV9296571Medicare PIN