Provider Demographics
NPI:1184107393
Name:GARDYASZ, EMILY (LAT, ATC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GARDYASZ
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12927 MEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154-2012
Mailing Address - Country:US
Mailing Address - Phone:215-499-7320
Mailing Address - Fax:
Practice Address - Street 1:4107 CEDAR CIRCLE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-2012
Practice Address - Country:US
Practice Address - Phone:813-974-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL56142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer