Provider Demographics
NPI:1528639960
Name:VAN DERVEER, GARY MITCHELL (LMT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MITCHELL
Last Name:VAN DERVEER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GARY M. VAN DERVEER
Mailing Address - Street 2:3935 E. GREENWAY RD APT. 205
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4671
Mailing Address - Country:US
Mailing Address - Phone:602-497-7422
Mailing Address - Fax:
Practice Address - Street 1:3935 E GREENWAY RD APT 205
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4671
Practice Address - Country:US
Practice Address - Phone:602-497-7422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-14602225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMT-14602OtherAZ STATE MASSAGE BOARD