Provider Demographics
NPI:1619470457
Name:LOUDER, CORLEE BERTELSON (PT)
Entity Type:Individual
Prefix:MRS
First Name:CORLEE
Middle Name:BERTELSON
Last Name:LOUDER
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 1:6463 W H AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-8557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:308 GREENVILLE BLVD SE STE B3
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5758
Practice Address - Country:US
Practice Address - Phone:252-215-5225
Practice Address - Fax:252-215-5226
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014299225100000X
NCP17877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist