Provider Demographics
NPI:1487816542
Name:VANDENBERG, STEVE MARK
Entity Type:Individual
Prefix:
First Name:STEVE
Middle Name:MARK
Last Name:VANDENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E MAIN ST
Mailing Address - Street 2:104
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2494
Mailing Address - Country:US
Mailing Address - Phone:248-349-5050
Mailing Address - Fax:
Practice Address - Street 1:235 E MAIN ST
Practice Address - Street 2:104
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-2494
Practice Address - Country:US
Practice Address - Phone:248-349-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003071225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist