Provider Demographics
NPI:1982785259
Name:DERUITER, SHELLY L (PT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:DERUITER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:L
Other - Last Name:VOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:646 S WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-9121
Mailing Address - Country:US
Mailing Address - Phone:616-994-8136
Mailing Address - Fax:616-994-8162
Practice Address - Street 1:646 S WAVERLY RD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-9121
Practice Address - Country:US
Practice Address - Phone:616-994-8136
Practice Address - Fax:616-994-8162
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0449561Medicaid
IA35426OtherWELLMARK
IAI11131Medicare ID - Type Unspecified