Provider Demographics
NPI:1477229300
Name:VANDIVORT, BETHANY A (ATC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:A
Last Name:VANDIVORT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23155 23RD AVE W
Mailing Address - Street 2:
Mailing Address - City:BRIER
Mailing Address - State:WA
Mailing Address - Zip Code:98036-8383
Mailing Address - Country:US
Mailing Address - Phone:425-835-1747
Mailing Address - Fax:
Practice Address - Street 1:23155 23RD AVE W
Practice Address - Street 2:
Practice Address - City:BRIER
Practice Address - State:WA
Practice Address - Zip Code:98036-8383
Practice Address - Country:US
Practice Address - Phone:425-835-1747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer