Provider Demographics
NPI:1770839524
Name:KOUDELE, JOANNA DREW (DPT)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:DREW
Last Name:KOUDELE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1396B WESTGATE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2932
Mailing Address - Country:US
Mailing Address - Phone:336-331-3277
Mailing Address - Fax:336-331-3279
Practice Address - Street 1:1396B WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2932
Practice Address - Country:US
Practice Address - Phone:336-331-3277
Practice Address - Fax:336-331-3279
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2025-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP20594225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200975610BMedicaid