Provider Demographics
NPI:1386377125
Name:GARDENHIRE, REBECCA AILEEN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:AILEEN
Last Name:GARDENHIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-3122
Mailing Address - Country:US
Mailing Address - Phone:970-248-1203
Mailing Address - Fax:970-248-1291
Practice Address - Street 1:1100 NORTH AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-3122
Practice Address - Country:US
Practice Address - Phone:970-248-1203
Practice Address - Fax:970-248-1291
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00015902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000013844OtherNATIONAL ATHLETIC TRAINERS' ASSOCIATION BOARD OF CERTIFICATION