Provider Demographics
NPI:1003193236
Name:KERANEN, STEPHANIE (COTA)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:KERANEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 5TH ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2867
Mailing Address - Country:US
Mailing Address - Phone:920-277-6974
Mailing Address - Fax:
Practice Address - Street 1:2305 SAN LUIS PL
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5211
Practice Address - Country:US
Practice Address - Phone:920-494-5231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4715-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant