Provider Demographics
NPI: | 1619900263 |
---|---|
Name: | VAN DUIVENBODE, INGRID J (PT) |
Entity Type: | Individual |
Prefix: | |
First Name: | INGRID |
Middle Name: | J |
Last Name: | VAN DUIVENBODE |
Suffix: | |
Gender: | F |
Credentials: | PT |
Other - Prefix: | |
Other - First Name: | INGRID |
Other - Middle Name: | J |
Other - Last Name: | HATTON |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | PT |
Mailing Address - Street 1: | 100 GANNETT DR STE C |
Mailing Address - Street 2: | |
Mailing Address - City: | SOUTH PORTLAND |
Mailing Address - State: | ME |
Mailing Address - Zip Code: | 04106-5900 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 207-828-0361 |
Mailing Address - Fax: | 207-874-1483 |
Practice Address - Street 1: | 100 FODEN RD, WEST |
Practice Address - Street 2: | SUITE 205 |
Practice Address - City: | SOUTH PORLAND |
Practice Address - State: | ME |
Practice Address - Zip Code: | 04106-2327 |
Practice Address - Country: | US |
Practice Address - Phone: | 207-780-8860 |
Practice Address - Fax: | 207-780-8857 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-08 |
Last Update Date: | 2020-10-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
ME | PT2381 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ME | 338210099 | Medicaid | |
079062 | Other | ANTHEM | |
7278436 | Other | AETNA | |
079062 | Other | ANTHEM |