Provider Demographics
NPI:1689366973
Name:GARDNER, MATTHEW (OTR)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 DARBONNE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-4714
Mailing Address - Country:US
Mailing Address - Phone:318-267-5662
Mailing Address - Fax:
Practice Address - Street 1:105 BLANCHARD ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7369
Practice Address - Country:US
Practice Address - Phone:318-398-9940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200718225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty