Provider Demographics
NPI:1841964145
Name:GARDNER, ALYSSA (PTA)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 STATE ROAD 60 W
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:IN
Mailing Address - Zip Code:47446-5601
Mailing Address - Country:US
Mailing Address - Phone:812-508-1660
Mailing Address - Fax:
Practice Address - Street 1:6301 BASS RD
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-9384
Practice Address - Country:US
Practice Address - Phone:812-508-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06006260A225200000X
KYA04234225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant