Provider Demographics
NPI:1093527814
Name:GARDINER, ELYSE
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:GARDINER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELYSE
Other - Middle Name:
Other - Last Name:MAZURKIEWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8565 STULL RD
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-9585
Mailing Address - Country:US
Mailing Address - Phone:586-638-6302
Mailing Address - Fax:
Practice Address - Street 1:58 PARKLAND PLZ STE 100
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-6208
Practice Address - Country:US
Practice Address - Phone:734-222-8515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501302000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist