Healthcare Provider Details

I. General information

NPI: 1427234749
Provider Name (Legal Business Name): REBECCA LYNN GARDNER-REILLY MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19349 HIGHLAND DR
NEW BUFFALO MI
49117-8942
US

IV. Provider business mailing address

19349 HIGHLAND DR
NEW BUFFALO MI
49117-8942
US

V. Phone/Fax

Practice location:
  • Phone: 269-205-3669
  • Fax: 269-238-3771
Mailing address:
  • Phone: 773-824-6306
  • Fax: 269-238-3771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501302457
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05015174A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: