Provider Demographics
NPI:1174221238
Name:VANDERMYDEN, SHIRLEY (LMT)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:VANDERMYDEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-4302
Mailing Address - Country:US
Mailing Address - Phone:406-388-1335
Mailing Address - Fax:
Practice Address - Street 1:2304 N 7TH AVE STE E
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-2571
Practice Address - Country:US
Practice Address - Phone:406-388-1335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-260225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist