Provider Demographics
NPI:1063777613
Name:CLODFELTER, KATIE JO (LPTA)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:JO
Last Name:CLODFELTER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3801 OLD BRUCEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-3889
Mailing Address - Country:US
Mailing Address - Phone:812-886-4677
Mailing Address - Fax:812-886-4678
Practice Address - Street 1:801 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3715
Practice Address - Country:US
Practice Address - Phone:217-443-3106
Practice Address - Fax:217-443-3187
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004650225200000X
IN06004433A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant