Provider Demographics
NPI:1184620478
Name:GARDNER, KELLY A (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:SPIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:70 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:NY
Mailing Address - Zip Code:13605-3102
Mailing Address - Country:US
Mailing Address - Phone:315-232-2225
Mailing Address - Fax:315-232-2800
Practice Address - Street 1:307 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NY
Practice Address - Zip Code:13624-1022
Practice Address - Country:US
Practice Address - Phone:315-285-5159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02302812Medicaid