Provider Demographics
NPI:1265066229
Name:GARDNER, KEVIN GREGORY (MT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:GREGORY
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 KENMORE AVE
Mailing Address - Street 2:SUITE 121
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1203
Mailing Address - Country:US
Mailing Address - Phone:703-861-0890
Mailing Address - Fax:
Practice Address - Street 1:4701 KENMORE AVE
Practice Address - Street 2:SUITE 121
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-2230
Practice Address - Country:US
Practice Address - Phone:703-861-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019012178225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4701Medicaid