Provider Demographics
NPI:1417626516
Name:VANDENDAELE, MATTHEW (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VANDENDAELE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22120 MIDLAND DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66226-3554
Mailing Address - Country:US
Mailing Address - Phone:913-745-4064
Mailing Address - Fax:
Practice Address - Street 1:22120 MIDLAND DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66226-3554
Practice Address - Country:US
Practice Address - Phone:913-745-4064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-068982251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic