Provider Demographics
NPI:1902112469
Name:VANDER BLOOMEN, KELLY J (PT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:VANDER BLOOMEN
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 1:700 S HARBOUR ISLAND BLVD UNIT 513
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-6705
Mailing Address - Country:US
Mailing Address - Phone:813-833-2663
Mailing Address - Fax:
Practice Address - Street 1:4107 N HIMES AVE STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6645
Practice Address - Country:US
Practice Address - Phone:813-874-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11510225100000X
AZ9316225100000X
CA43565225100000X
TX1217489225100000X
FL38019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist