Healthcare Provider Details

I. General information

NPI: 1215911748
Provider Name (Legal Business Name): MARTIE JOHANNA VANWERKUM-GLIDDEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 MYRTLE AVE
EUREKA CA
95501-3323
US

IV. Provider business mailing address

2103 MYRTLE AVE
EUREKA CA
95501-3323
US

V. Phone/Fax

Practice location:
  • Phone: 707-445-9150
  • Fax: 707-444-1372
Mailing address:
  • Phone: 707-445-9150
  • Fax: 707-444-1372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT11721
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: