Provider Demographics
NPI:1013213578
Name:STEVENS, NICOLE SOPHIA (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SOPHIA
Last Name:STEVENS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:SOPHIA
Other - Last Name:GUTBROD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:855 N WESTHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7668
Mailing Address - Country:US
Mailing Address - Phone:920-456-7000
Mailing Address - Fax:
Practice Address - Street 1:3151 EDEN CT
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-6639
Practice Address - Country:US
Practice Address - Phone:920-651-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4981-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist