Provider Demographics
NPI:1760559405
Name:VANDERMOLEN, MYRNA F (OTR)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:F
Last Name:VANDERMOLEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 MT EVE RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-7015
Mailing Address - Country:US
Mailing Address - Phone:845-651-2969
Mailing Address - Fax:
Practice Address - Street 1:2277 GOSHEN TPKE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-4032
Practice Address - Country:US
Practice Address - Phone:845-692-4391
Practice Address - Fax:845-692-4397
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007347225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY87763OtherGHI
NYQ95551OtherEMPIREBLUECROSSBLUESHIELD
NYQ95641Medicare ID - Type Unspecified