Provider Demographics
NPI:1902874944
Name:BOALDIN, KATHRYN MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
Last Name:BOALDIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:MARIE
Other - Last Name:HANISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:850 43RD AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:815 W TOWER PARK DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-9026
Practice Address - Country:US
Practice Address - Phone:319-233-6995
Practice Address - Fax:319-233-7083
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA03885OtherIOWA PT LICENSE