Healthcare Provider Details

I. General information

NPI: 1831413137
Provider Name (Legal Business Name): MARY E VANDER HEIDEN MA, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2010
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CENTRAL FLORIDA BLVD UCF SPORTS MEDICINE
ORLANDO FL
32816-3555
US

IV. Provider business mailing address

PO BOX 163555
ORLANDO FL
32816-3555
US

V. Phone/Fax

Practice location:
  • Phone: 407-823-0963
  • Fax: 407-823-6744
Mailing address:
  • Phone: 407-823-0963
  • Fax: 407-823-6744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 1371
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: