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General NPI Number Information
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NPI Number | 1528639960
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Entity Type | Individual
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Provider Name | GARY MITCHELL VAN DERVEER LMT
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Gender | Male
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Dates
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Enumeration Date | 07/07/2021
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Last Update Date | 07/07/2021
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Provider Practice Location Address
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Address Line | 3935 E GREENWAY RD APT 205
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City | PHOENIX
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State | AZ
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Zip | 85032-4671
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Country | US
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Telephone | 602-497-7422
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Fax |
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Provider Business Mailing Address
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Address Line | GARY M. VAN DERVEER 3935 E. GREENWAY RD APT. 205
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City | PHOENIX
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State | AZ
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Zip | 85032-4671
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Country | US
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Telephone | 602-497-7422
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT-14602
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License Number State | AZ
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