Provider Demographics
NPI:1245449651
Name:VANDYCK, WALTER R (OTR)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:R
Last Name:VANDYCK
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CANONCHET ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-3802
Mailing Address - Country:US
Mailing Address - Phone:401-751-0109
Mailing Address - Fax:
Practice Address - Street 1:SPRINGFIELD MIDDLE SCHOOL, PROVIDENE SCHOOL DEPARTMENT
Practice Address - Street 2:152 SPRINGFIELD ST
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909
Practice Address - Country:US
Practice Address - Phone:401-278-0557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI80225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist