Provider Demographics
NPI:1871075424
Name:VANSTAALDUINEN, MARIAH ELISABETH (OTR/L)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:ELISABETH
Last Name:VANSTAALDUINEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 BREEZY SHORE RD
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NC
Mailing Address - Zip Code:27808-9598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 E 12TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3408
Practice Address - Country:US
Practice Address - Phone:252-944-3410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10644225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist