Provider Demographics
NPI:1821719162
Name:VANDERBLOOMEN, MACKENZIE ELLEN (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ELLEN
Last Name:VANDERBLOOMEN
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 EDMONSON CIR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-7227
Mailing Address - Country:US
Mailing Address - Phone:920-242-3672
Mailing Address - Fax:
Practice Address - Street 1:2206 SPEDALE CT STE 6
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-6138
Practice Address - Country:US
Practice Address - Phone:615-220-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7411225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist