Provider Demographics
NPI:1992884258
Name:GARDNER, MARY ELIZABETH (MPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:MICHALOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:1708 S CHASE LN
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-9489
Mailing Address - Country:US
Mailing Address - Phone:410-822-4613
Mailing Address - Fax:410-822-6534
Practice Address - Street 1:11022 NICHOLAS LN
Practice Address - Street 2:SUITE 1
Practice Address - City:OCEAN PINES
Practice Address - State:MD
Practice Address - Zip Code:21811-3352
Practice Address - Country:US
Practice Address - Phone:410-822-4613
Practice Address - Fax:410-822-6534
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD435138000Medicaid
MD216538Medicare ID - Type Unspecified