Provider Demographics
NPI:1265865083
Name:VAN GORDER, DANIELLE MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:VAN GORDER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 FRONT ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-1559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 FRONT ST
Practice Address - Street 2:SUITE D
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1559
Practice Address - Country:US
Practice Address - Phone:607-754-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036581174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist