Provider Demographics
NPI:1215911748
Name:VANWERKUM-GLIDDEN, MARTIE JOHANNA (PT)
Entity type:Individual
Prefix:MRS
First Name:MARTIE
Middle Name:JOHANNA
Last Name:VANWERKUM-GLIDDEN
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 1:2103 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3323
Mailing Address - Country:US
Mailing Address - Phone:707-445-9150
Mailing Address - Fax:707-444-1372
Practice Address - Street 1:2103 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3323
Practice Address - Country:US
Practice Address - Phone:707-445-9150
Practice Address - Fax:707-444-1372
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11721225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPT117211Medicare ID - Type Unspecified
X50523Medicare UPIN