Provider Demographics
NPI:1639180441
Name:GARDNER, ELIZABETH K (OT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:K
Last Name:GARDNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:K
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3210 200TH PL SW
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6934
Mailing Address - Country:US
Mailing Address - Phone:425-353-5656
Mailing Address - Fax:
Practice Address - Street 1:3210 200TH PL SW
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6934
Practice Address - Country:US
Practice Address - Phone:425-353-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00001585225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA23929UOtherREGENCE BLUE SHIELD PIN