Provider Demographics
NPI:1386620235
Name:VAN DER HORST, MARIEKE (PT)
Entity type:Individual
Prefix:MS
First Name:MARIEKE
Middle Name:
Last Name:VAN DER HORST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 BRIAR OAK WAY
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-8043
Mailing Address - Country:US
Mailing Address - Phone:386-848-3091
Mailing Address - Fax:
Practice Address - Street 1:26 N BEACH ST
Practice Address - Street 2:SUITE B
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5663
Practice Address - Country:US
Practice Address - Phone:386-673-0201
Practice Address - Fax:386-677-8143
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00165078OtherRAILROAD MEDICARE PIN
FLY9430OtherBCBS
FLP00165078OtherRAILROAD MEDICARE PIN
FLY9430OtherBCBS
FLY9430XMedicare ID - Type Unspecified