Provider Demographics
NPI:1740963057
Name:GLOUDEMANS, KARISA NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:KARISA
Middle Name:NICOLE
Last Name:GLOUDEMANS
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:W6641 RICKEY LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-8502
Mailing Address - Country:US
Mailing Address - Phone:920-419-4767
Mailing Address - Fax:
Practice Address - Street 1:370 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1632
Practice Address - Country:US
Practice Address - Phone:920-531-2031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-11
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16514-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist