Healthcare Provider Details

I. General information

NPI: 1275614281
Provider Name (Legal Business Name): ELIZABETH ROSE VANDENBROEK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 KINGSLEY AVE
ORANGE PARK FL
32073-4830
US

IV. Provider business mailing address

3498 RUSTIC OAK TRL
MIDDLEBURG FL
32068-5811
US

V. Phone/Fax

Practice location:
  • Phone: 904-616-0572
  • Fax:
Mailing address:
  • Phone: 904-616-0572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number26200
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: