Healthcare Provider Details

I. General information

NPI: 1962147215
Provider Name (Legal Business Name): DANIETTE S GARDNER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANIETTE ST MARTIN PT, DPT

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

659 NE US HIGHWAY 19 UNIT 1
CRYSTAL RIVER FL
34429-4240
US

IV. Provider business mailing address

PO BOX 2060 NULL
LECANTO FL
34460
US

V. Phone/Fax

Practice location:
  • Phone: 352-563-0911
  • Fax:
Mailing address:
  • Phone: 844-797-8425
  • Fax: 352-513-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-32326
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number43852
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: