Provider Demographics
NPI:1851564454
Name:GARDNER, STACEY J (PT)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:J
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 MAXWELL RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-4814
Mailing Address - Country:US
Mailing Address - Phone:419-474-8294
Mailing Address - Fax:
Practice Address - Street 1:200 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ROSSFORD
Practice Address - State:OH
Practice Address - Zip Code:43460-1277
Practice Address - Country:US
Practice Address - Phone:419-666-2273
Practice Address - Fax:419-666-2274
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH9489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist