Provider Demographics
NPI:1710964184
Name:VANCAMPEN, MATTHEW D (MSPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:VANCAMPEN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 36TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4741
Mailing Address - Country:US
Mailing Address - Phone:503-540-8701
Mailing Address - Fax:503-371-8772
Practice Address - Street 1:109 MCNARY ESTATES DR N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303
Practice Address - Country:US
Practice Address - Phone:503-463-5231
Practice Address - Fax:503-463-5175
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3846225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298482Medicaid
OR298482Medicaid