Provider Demographics
NPI:1174816524
Name:VANDENBOSCH, KARLA JOY (PT)
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:JOY
Last Name:VANDENBOSCH
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 1:323 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-3200
Mailing Address - Country:US
Mailing Address - Phone:605-256-8915
Mailing Address - Fax:605-256-8983
Practice Address - Street 1:1423 NE 4TH ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042-1236
Practice Address - Country:US
Practice Address - Phone:605-256-9053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist