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
StateLicense IDTaxonomies
MEPT2381225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME338210099Medicaid
079062OtherANTHEM
7278436OtherAETNA
079062OtherANTHEM