Provider Demographics
NPI:1124270301
Name:LABODDA, KORINE ANN (OTR)
Entity type:Individual
Prefix:MRS
First Name:KORINE
Middle Name:ANN
Last Name:LABODDA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8303 VIRGINIA CIR
Mailing Address - Street 2:
Mailing Address - City:WIND LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53185-1384
Mailing Address - Country:US
Mailing Address - Phone:262-895-6766
Mailing Address - Fax:
Practice Address - Street 1:8303 VIRGINIA CIR
Practice Address - Street 2:
Practice Address - City:WIND LAKE
Practice Address - State:WI
Practice Address - Zip Code:53185-1384
Practice Address - Country:US
Practice Address - Phone:262-895-6766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-19
Last Update Date:2008-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1492-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40691400Medicaid