Provider Demographics
NPI:1649976176
Name:FUELBERTH, SAVANNAH RENEE (DPT)
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:RENEE
Last Name:FUELBERTH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SAVANNAH
Other - Middle Name:RENEE
Other - Last Name:WIEDOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1130 S SCOTT BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-2909
Mailing Address - Country:US
Mailing Address - Phone:319-354-2429
Mailing Address - Fax:319-338-5775
Practice Address - Street 1:2769 HEARTLAND DR STE 301
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2732
Practice Address - Country:US
Practice Address - Phone:319-545-4121
Practice Address - Fax:319-545-4128
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA117347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06-65463Medicaid