Healthcare Provider Details

I. General information

NPI: 1952529901
Provider Name (Legal Business Name): MARY GERALDINE GARDNER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 SALEM TPKE
BOZRAH CT
06334-1517
US

IV. Provider business mailing address

85A FAIRHAVEN RD
NIANTIC CT
06357-1739
US

V. Phone/Fax

Practice location:
  • Phone: 860-885-6240
  • Fax: 860-885-6241
Mailing address:
  • Phone: 860-739-8945
  • Fax: 860-885-6241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number04587
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: