Provider Demographics
NPI:1790753903
Name:VLIETSTRA, CHRISTINE R (PT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:R
Last Name:VLIETSTRA
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 1:315 TURWILL LN
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-4231
Mailing Address - Country:US
Mailing Address - Phone:269-343-8170
Mailing Address - Fax:269-382-2388
Practice Address - Street 1:315 TURWILL LN
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-4231
Practice Address - Country:US
Practice Address - Phone:269-343-8170
Practice Address - Fax:269-382-2388
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650C913940OtherBCBS
MIN64470010Medicare PIN
MI0C97625145Medicare PIN