Provider Demographics
NPI:1336747740
Name:GARDENHIRE, EMILY N (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:N
Last Name:GARDENHIRE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:MOKOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1595 S CALUMET RD STE 3
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2389
Practice Address - Country:US
Practice Address - Phone:219-764-4888
Practice Address - Fax:199-894-2582
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006927A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196020AMedicaid