Provider Demographics
NPI:1831413137
Name:VANDER HEIDEN, MARY E (MA, ATC, LAT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:VANDER HEIDEN
Suffix:
Gender:F
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 163555
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32816-3555
Mailing Address - Country:US
Mailing Address - Phone:407-823-0963
Mailing Address - Fax:407-823-6744
Practice Address - Street 1:4000 CENTRAL FLORIDA BLVD
Practice Address - Street 2:UCF SPORTS MEDICINE
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32816-3555
Practice Address - Country:US
Practice Address - Phone:407-823-0963
Practice Address - Fax:407-823-6744
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 13712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer