Provider Demographics
NPI:1265574420
Name:VAN DER MERWE, MARIJCKE
Entity type:Individual
Prefix:
First Name:MARIJCKE
Middle Name:
Last Name:VAN DER MERWE
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 1:2848 COBBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-1620
Mailing Address - Country:US
Mailing Address - Phone:727-709-6133
Mailing Address - Fax:
Practice Address - Street 1:2848 COBBLESTONE DR
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1620
Practice Address - Country:US
Practice Address - Phone:727-709-6133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT133532251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL883427000Medicaid