Basic Information
| Provider Information | |||||||||
| NPI: | 1740648526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | M. EILEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 12 JOSIAH DR | ||||||||
| Address2: | |||||||||
| City: | UPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015681451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087698549 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 110 HAVERHILL RD | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | AMESBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019132123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783884500 | ||||||||
| FaxNumber: | 9788347229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2016 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT38698 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 19441 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 05014800A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.