Provider Demographics
NPI:1588812721
Name:VAN DE PUT, AGNES LEONIA (PT)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:LEONIA
Last Name:VAN DE PUT
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 1:7809 STEFENONI CT UNIT A
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3536
Mailing Address - Country:US
Mailing Address - Phone:808-937-3943
Mailing Address - Fax:
Practice Address - Street 1:6914 SEBASTOPOL AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3459
Practice Address - Country:US
Practice Address - Phone:707-327-0998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2160225100000X
CA25323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist