Basic Information
| Provider Information | |||||||||
| NPI: | 1003343260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDEVEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3622 BROOKSTONE DR | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385065802 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5001 STATESMAN DR | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750632414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007884815 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2017 | ||||||||
| LastUpdateDate: | 01/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01748200 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 10033 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.