Provider Demographics
NPI:1376820662
Name:VONDERHAAR, MANDI ELISE (PT)
Entity Type:Individual
Prefix:DR
First Name:MANDI
Middle Name:ELISE
Last Name:VONDERHAAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:DR
Other - First Name:MANDI
Other - Middle Name:ELISE
Other - Last Name:FETTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:67 W DUNEDIN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-4001
Mailing Address - Country:US
Mailing Address - Phone:330-697-8327
Mailing Address - Fax:614-850-0540
Practice Address - Street 1:880 KINNEAR RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-1443
Practice Address - Country:US
Practice Address - Phone:330-697-8327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38346225100000X
OHPT.013298225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH12664347OtherCAQH