Healthcare Provider Details

I. General information

NPI: 1477316503
Provider Name (Legal Business Name): CASSANDRA JO GARDNER TRS/CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4558 ADAMS AVE
SOUTH OGDEN UT
84403-4104
US

IV. Provider business mailing address

4558 ADAMS AVE
SOUTH OGDEN UT
84403-4104
US

V. Phone/Fax

Practice location:
  • Phone: 435-823-3402
  • Fax:
Mailing address:
  • Phone: 435-823-3402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number11392749-4002
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: