Healthcare Provider Details

I. General information

NPI: 1124368683
Provider Name (Legal Business Name): CARLA JEAN VANDENBURGH MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 LEBANON AVE STE 101
BELLEVILLE IL
62221-2491
US

IV. Provider business mailing address

3212 HUNTERS WAY
BELLEVILLE IL
62221-3471
US

V. Phone/Fax

Practice location:
  • Phone: 618-978-7407
  • Fax:
Mailing address:
  • Phone: 618-978-7407
  • Fax: 618-277-6672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number217.011790
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: