Provider Demographics
NPI:1821372962
Name:VANDER BLOOMEN, CHRISTINE (LMT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:VANDER BLOOMEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4537
Mailing Address - Country:US
Mailing Address - Phone:920-682-6999
Mailing Address - Fax:
Practice Address - Street 1:822 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4537
Practice Address - Country:US
Practice Address - Phone:920-682-6999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10209-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist