Basic Information
| Provider Information | |||||||||
| NPI: | 1487015657 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GARDNER | ||||||||
| FirstName: | KALA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 10004 204TH AVE E | ||||||||
| Address2: | STE 3100 | ||||||||
| City: | BONNEY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983916539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538637510 | ||||||||
| FaxNumber: | 2538635970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2016 | ||||||||
| LastUpdateDate: | 12/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OC014346 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | OT60699125 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.