Provider Demographics
NPI:1003343260
Name:VANDEVEN, MARY ELIZABETH (DPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:VANDEVEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13937 S SPRAGUE LN STE 100
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7864
Practice Address - Country:US
Practice Address - Phone:385-308-8034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT39443225100000X
MEPT6402225100000X
ALPTH11154225100000X
IL070.027215225100000X
TX1373888225100000X
IN05014994A225100000X
PAPT026407225100000X
KS11-07291225100000X
RIPT03657225100000X
TN10033225100000X
NY050472225100000X
CA304318225100000X
WYPT-2324225100000X
OHPT020768225100000X
COPLL.0016925225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist