Provider Demographics
NPI:1750121414
Name:VANDERVEEN, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:VANDERVEEN
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 1:957 7TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:OR
Mailing Address - Zip Code:97127-9231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:957 7TH STREET EXT
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:OR
Practice Address - Zip Code:97127-9231
Practice Address - Country:US
Practice Address - Phone:971-237-8856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24659225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist