Healthcare Provider Details

I. General information

NPI: 1699631374
Provider Name (Legal Business Name): ELLYN SUE VANDENBERG LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2025
Last Update Date: 12/26/2025
Certification Date: 12/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2955 N HWY 97
BEND OR
97703-7559
US

IV. Provider business mailing address

63987 SUNSET DR
BEND OR
97703-8590
US

V. Phone/Fax

Practice location:
  • Phone: 541-728-3004
  • Fax:
Mailing address:
  • Phone: 541-280-5045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5129
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: