Provider Demographics
NPI:1861785156
Name:BODDEN, KAREN LEA (PT)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:LEA
Last Name:BODDEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:LEA
Other - Last Name:SCHAUMBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:360 S MOUNTIN DR
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53050-1498
Mailing Address - Country:US
Mailing Address - Phone:920-387-7560
Mailing Address - Fax:
Practice Address - Street 1:360 S MOUNTIN DR
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-1498
Practice Address - Country:US
Practice Address - Phone:920-387-7560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5174-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist