Healthcare Provider Details

I. General information

NPI: 1306063847
Provider Name (Legal Business Name): JUDITH LEFFLER GARDNER P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 CAPRI DR
GAINESVILLE GA
30506-1752
US

IV. Provider business mailing address

2475 HAWTHORNE LN
GAINESVILLE GA
30506-1905
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-1633
  • Fax: 770-536-0197
Mailing address:
  • Phone: 770-718-9238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT008231
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: