Provider Demographics
NPI:1982843835
Name:GARDNER, EMILY BROOKS (PTA)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:BROOKS
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 1:303 E SIMMONS AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-1847
Mailing Address - Country:US
Mailing Address - Phone:252-792-1652
Mailing Address - Fax:
Practice Address - Street 1:1624 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-8761
Practice Address - Country:US
Practice Address - Phone:252-946-9570
Practice Address - Fax:252-946-3715
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC2612225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant