Provider Demographics
NPI:1306326533
Name:GARDNER, BRENNA (LMT)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6018 BAYSHORE DR
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9065
Mailing Address - Country:US
Mailing Address - Phone:801-347-4888
Mailing Address - Fax:
Practice Address - Street 1:150 S 600 E STE 3B
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1961
Practice Address - Country:US
Practice Address - Phone:801-359-5149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4902733-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist