Provider Demographics
NPI:1104988112
Name:SCHROEDER, KARENA DIANE (DPT)
Entity type:Individual
Prefix:MRS
First Name:KARENA
Middle Name:DIANE
Last Name:SCHROEDER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:KARENA
Other - Middle Name:DIANE
Other - Last Name:RUNYON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4251 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:260-432-4700
Mailing Address - Fax:260-459-9262
Practice Address - Street 1:3534 BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809
Practice Address - Country:US
Practice Address - Phone:260-478-5230
Practice Address - Fax:260-478-5235
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008969A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000482874OtherANTHEM BCBS
IN200838660Medicaid
IN100257920OtherMEDICAID - GROUP
IN1424OtherPHP
IN35179001202OtherCARESOURCE
IN4423623OtherAETNA
IN200838660Medicaid