Provider Demographics
NPI:1689285942
Name:GARDNER, ROBERT (LMT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 S EAGLE ST
Mailing Address - Street 2:
Mailing Address - City:TERRYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06786-6705
Mailing Address - Country:US
Mailing Address - Phone:203-910-1394
Mailing Address - Fax:
Practice Address - Street 1:444 WOLCOTT RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2639
Practice Address - Country:US
Practice Address - Phone:203-879-4695
Practice Address - Fax:203-879-4696
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002617225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist