Healthcare Provider Details

I. General information

NPI: 1003140393
Provider Name (Legal Business Name): ERIN GARDNER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13011 SUMMERFIELD SQUARE DR
RIVERVIEW FL
33578-7402
US

IV. Provider business mailing address

13011 SUMMERFIELD SQUARE DR
RIVERVIEW FL
33578-7402
US

V. Phone/Fax

Practice location:
  • Phone: 813-374-2209
  • Fax: 813-374-2211
Mailing address:
  • Phone: 813-374-2209
  • Fax: 813-374-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA24145
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: