Provider Demographics
NPI:1629229315
Name:VANDYCK, MARLA THURMAN (PT)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:THURMAN
Last Name:VANDYCK
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 1:195 MILES ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-1820
Mailing Address - Country:US
Mailing Address - Phone:706-546-1333
Mailing Address - Fax:706-546-5807
Practice Address - Street 1:1088C BAXTER ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6316
Practice Address - Country:US
Practice Address - Phone:706-549-7400
Practice Address - Fax:706-549-7399
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT001132225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT001132OtherPHYSICAL THERAPIST LICENSE