Provider Demographics
NPI:1225531825
Name:VANDER VLIET, SHONNY H (ATC)
Entity Type:Individual
Prefix:
First Name:SHONNY
Middle Name:H
Last Name:VANDER VLIET
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:SHONNY
Other - Middle Name:
Other - Last Name:ROLSTON-LUECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:7332 MATHESON DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-8239
Mailing Address - Country:US
Mailing Address - Phone:970-690-3551
Mailing Address - Fax:
Practice Address - Street 1:7332 MATHESON DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-8239
Practice Address - Country:US
Practice Address - Phone:970-690-3551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-10
Last Update Date:2018-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00005742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer