Provider Demographics
NPI:1386930329
Name:GARDNER, TERRI S (COTA/L)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:S
Last Name:GARDNER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 LUTHERAN CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825
Mailing Address - Country:US
Mailing Address - Phone:814-849-2103
Mailing Address - Fax:
Practice Address - Street 1:2501 E MOORE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4751
Practice Address - Country:US
Practice Address - Phone:501-268-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP007077224Z00000X
ARA 751224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant