Provider Demographics
NPI:1225439987
Name:VANDENBERG, ASHLEY NICOLE (PT,DPT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY
Mailing Address - Street 2:STE 307
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:
Practice Address - Street 1:901 W MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1581
Practice Address - Country:US
Practice Address - Phone:616-897-7055
Practice Address - Fax:616-897-7366
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist