Provider Demographics
NPI:1770839524
Name:KOUDELE, JOANNA DREW (DPT)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:DREW
Last Name:KOUDELE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426A MCCALL RD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-5032
Mailing Address - Country:US
Mailing Address - Phone:785-776-0670
Mailing Address - Fax:785-776-0096
Practice Address - Street 1:4201B ANDERSON AVE
Practice Address - Street 2:STE 1A
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503
Practice Address - Country:US
Practice Address - Phone:785-539-5555
Practice Address - Fax:785-539-4551
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-04149225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200975610BMedicaid