Healthcare Provider Details

I. General information

NPI: 1811174501
Provider Name (Legal Business Name): HEATHER VANDERMALLIEDPT DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 01/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 HIGHLAND AVE
ROCHESTER NY
14620-3024
US

IV. Provider business mailing address

150 HIGHLAND AVE
ROCHESTER NY
14620-3024
US

V. Phone/Fax

Practice location:
  • Phone: 585-760-1295
  • Fax: 585-760-7961
Mailing address:
  • Phone: 585-760-1295
  • Fax: 585-760-7961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number028073
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: