Provider Demographics
NPI:1326456245
Name:VANDERMEUSE, THEODORE (ATC/LAT)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:VANDERMEUSE
Suffix:
Gender:M
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 NEW PINERY RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9240
Mailing Address - Country:US
Mailing Address - Phone:608-745-6290
Mailing Address - Fax:
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9240
Practice Address - Country:US
Practice Address - Phone:608-745-6290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer