Provider Demographics
NPI:1366825218
Name:VANDERWEELE, TIFFANY (DPT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:VANDERWEELE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:BASORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1736 GEZON PKWY SW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 JOHN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-2870
Practice Address - Country:US
Practice Address - Phone:269-341-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016919225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist