Provider Demographics
NPI:1952529901
Name:GARDNER, MARY GERALDINE (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:GERALDINE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
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Mailing Address - Street 1:85A FAIRHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-1739
Mailing Address - Country:US
Mailing Address - Phone:860-739-8945
Mailing Address - Fax:860-885-6241
Practice Address - Street 1:441 SALEM TPKE
Practice Address - Street 2:
Practice Address - City:BOZRAH
Practice Address - State:CT
Practice Address - Zip Code:06334-1517
Practice Address - Country:US
Practice Address - Phone:860-885-6240
Practice Address - Fax:860-885-6241
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT04587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist