Provider Demographics
NPI:1619990249
Name:VANDERBLOOMER, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VANDERBLOOMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10009 PARK CEDAR DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8935
Mailing Address - Country:US
Mailing Address - Phone:704-716-1024
Mailing Address - Fax:704-716-1025
Practice Address - Street 1:10009 PARK CEDAR DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8935
Practice Address - Country:US
Practice Address - Phone:704-716-1024
Practice Address - Fax:704-716-1025
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40301000Medicaid
WI40301000Medicaid