Provider Demographics
NPI:1255723334
Name:VANDEGOOR, MARIJKE
Entity type:Individual
Prefix:
First Name:MARIJKE
Middle Name:
Last Name:VANDEGOOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 QUEEN ANNE CT
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8455
Mailing Address - Country:US
Mailing Address - Phone:386-795-2737
Mailing Address - Fax:
Practice Address - Street 1:733 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4225
Practice Address - Country:US
Practice Address - Phone:386-756-0077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT13609225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist