Provider Demographics
NPI:1487843348
Name:VANDEREST, MARIOLA BEATA (PT)
Entity Type:Individual
Prefix:
First Name:MARIOLA
Middle Name:BEATA
Last Name:VANDEREST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 CASS LAKE RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:KEEGO HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48320
Mailing Address - Country:US
Mailing Address - Phone:248-706-1308
Mailing Address - Fax:248-706-1049
Practice Address - Street 1:2141 CASS LAKE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:KEEGO HARBOR
Practice Address - State:MI
Practice Address - Zip Code:48320
Practice Address - Country:US
Practice Address - Phone:248-706-1308
Practice Address - Fax:248-706-1049
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501005050OtherBOARD OF PHYSICAL THERAPY