Provider Demographics
NPI:1174906747
Name:VAN OTTERLOO, JANELLE
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:
Last Name:VAN OTTERLOO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 W TRADEWINDS ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-4112
Mailing Address - Country:US
Mailing Address - Phone:507-227-8714
Mailing Address - Fax:
Practice Address - Street 1:810 E 23RD ST FL 2
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-2135
Practice Address - Country:US
Practice Address - Phone:605-322-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD26212251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic