Provider Demographics
NPI:1043670227
Name:VAN DER HEIDE, PETER THEODORUS OTTO (DPT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:THEODORUS OTTO
Last Name:VAN DER HEIDE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 LINDLEY AVE
Mailing Address - Street 2:UNIT 121
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1904
Mailing Address - Country:US
Mailing Address - Phone:408-398-1163
Mailing Address - Fax:
Practice Address - Street 1:5500 LINDLEY AVE
Practice Address - Street 2:UNIT 121
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1904
Practice Address - Country:US
Practice Address - Phone:408-398-1163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist