Provider Demographics
NPI:1033518162
Name:VAN VLIET, EAN
Entity Type:Individual
Prefix:
First Name:EAN
Middle Name:
Last Name:VAN VLIET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5162 ANTON DR APT 301
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:323 WEST MONROE STREET
Practice Address - Street 2:
Practice Address - City:WYOCENA
Practice Address - State:WI
Practice Address - Zip Code:53969
Practice Address - Country:US
Practice Address - Phone:608-429-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1945225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant