Provider Demographics
NPI:1679010177
Name:VANDERLAAN, LUCAS JACOB (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:JACOB
Last Name:VANDERLAAN
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:LUCAS
Other - Middle Name:JACOB
Other - Last Name:VAN DER LAAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:28933 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-0923
Mailing Address - Country:US
Mailing Address - Phone:248-414-7592
Mailing Address - Fax:248-414-7661
Practice Address - Street 1:28933 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-0923
Practice Address - Country:US
Practice Address - Phone:248-414-7592
Practice Address - Fax:248-414-7661
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist