Provider Demographics
NPI:1558838508
Name:VANGAALEN, TEAIRA FAITHANGEL (PTA)
Entity Type:Individual
Prefix:
First Name:TEAIRA
Middle Name:FAITHANGEL
Last Name:VANGAALEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 N LITCHFIELD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-7805
Mailing Address - Country:US
Mailing Address - Phone:602-588-0320
Mailing Address - Fax:
Practice Address - Street 1:8811 N 51ST AVE STE 102
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4949
Practice Address - Country:US
Practice Address - Phone:623-915-2726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13842225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ013842OtherLICENSE