MEDICARE: CHANEL NICOLE VANDERHORST PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	23464	MD

General Provider Information

NPI Number	:	1760620306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANEL NICOLE VANDERHORST PT

Provider Business Mailing Address
First Line	:	PO BOX 356
Second Line	:
City	:	BURTONSVILLE
State	:	MD
Zip	:	20866-0356
Country	:	US
Telephone Number	:	301-421-1125
Fax Number	:	301-500-2175

Provider Business Practice Location Address
First Line	:	8865 STANFORD BLVD
Second Line	:	SUITE 114
City	:	COLUMBIA
State	:	MD
Zip	:	21045-5420
Country	:	US
Telephone Number	:	410-290-4480
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2009
Last Update Date	:	12/04/2018

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