Provider Demographics
NPI:1972634061
Name:VANDENBOS, ANGELA G (LMT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:G
Last Name:VANDENBOS
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 1:39 NE KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7539
Mailing Address - Country:US
Mailing Address - Phone:503-314-9162
Mailing Address - Fax:503-492-8560
Practice Address - Street 1:39 NE KELLY AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7539
Practice Address - Country:US
Practice Address - Phone:503-314-9162
Practice Address - Fax:503-492-8560
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6248225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist