Provider Demographics
NPI:1669944831
Name:GARDNER, ROSS (DPT)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SQUIRE POPE RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-6999
Mailing Address - Country:US
Mailing Address - Phone:208-613-7361
Mailing Address - Fax:843-892-8444
Practice Address - Street 1:211 SQUIRE POPE RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-6999
Practice Address - Country:US
Practice Address - Phone:208-613-7361
Practice Address - Fax:843-892-8444
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251P0200X
SC11763225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics