Healthcare Provider Details

I. General information

NPI: 1982761987
Provider Name (Legal Business Name): JEAN MARIE VANDERMARLIERE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1629 E DIVISION ST
RIVER FALLS WI
54022-1571
US

IV. Provider business mailing address

W5164 COUNTY ROAD G
BELDENVILLE WI
54003-5103
US

V. Phone/Fax

Practice location:
  • Phone: 715-426-4537
  • Fax: 715-426-4602
Mailing address:
  • Phone: 715-273-3891
  • Fax: 715-426-4602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number402-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: