Provider Demographics
NPI:1275797185
Name:VANDERWALL, KRISTOPHER JAY (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:JAY
Last Name:VANDERWALL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44273-8864
Mailing Address - Country:US
Mailing Address - Phone:330-769-4677
Mailing Address - Fax:
Practice Address - Street 1:265 CENTER ST
Practice Address - Street 2:
Practice Address - City:SEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44273-8864
Practice Address - Country:US
Practice Address - Phone:330-769-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH5321225100000X
OHPT.014382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist