Provider Demographics
NPI:1093811416
Name:VANDERVELDE, REIN (PT)
Entity Type:Individual
Prefix:
First Name:REIN
Middle Name:
Last Name:VANDERVELDE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:REINDER
Other - Middle Name:A
Other - Last Name:VAN DER VELDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2377 DUNN AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-6984
Mailing Address - Country:US
Mailing Address - Phone:904-751-6646
Mailing Address - Fax:904-751-6647
Practice Address - Street 1:2377 DUNN AVE STE 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-6984
Practice Address - Country:US
Practice Address - Phone:904-751-6646
Practice Address - Fax:904-751-6647
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT5670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist