Provider Demographics
NPI:1720822786
Name:GARDNER, CASSITY JAMIE RUSH
Entity type:Individual
Prefix:
First Name:CASSITY
Middle Name:JAMIE RUSH
Last Name:GARDNER
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 1:970 FORT WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-4328
Mailing Address - Country:US
Mailing Address - Phone:317-225-0824
Mailing Address - Fax:800-215-5075
Practice Address - Street 1:970 FORT WAYNE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4328
Practice Address - Country:US
Practice Address - Phone:317-225-0824
Practice Address - Fax:800-215-5075
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21605823225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist