Healthcare Provider Details

I. General information

NPI: 1083491658
Provider Name (Legal Business Name): KATIE GARDNER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/17/2023
Certification Date: 09/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17650 140TH AVE SE STE B7
RENTON WA
98058-6814
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 425-430-0700
  • Fax: 425-430-0710
Mailing address:
  • Phone: 866-370-8206
  • Fax: 517-435-3670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: