Healthcare Provider Details

I. General information

NPI: 1932437001
Provider Name (Legal Business Name): SARA LEA BODEM PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3173 WINDLAND DR
GREEN BAY WI
54311-7607
US

IV. Provider business mailing address

3173 WINDLAND DR
GREEN BAY WI
54311-7607
US

V. Phone/Fax

Practice location:
  • Phone: 920-469-7133
  • Fax:
Mailing address:
  • Phone: 920-469-7133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number1058-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: