Provider Demographics
NPI:1124375894
Name:VANDENDOLDER, RICHARD PETER (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:PETER
Last Name:VANDENDOLDER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4602
Mailing Address - Country:US
Mailing Address - Phone:952-993-5495
Mailing Address - Fax:952-993-2250
Practice Address - Street 1:6701 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4602
Practice Address - Country:US
Practice Address - Phone:952-993-5495
Practice Address - Fax:952-993-2250
Is Sole Proprietor?:No
Enumeration Date:2012-08-12
Last Update Date:2012-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101359225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist