Provider Demographics
NPI:1093370116
Name:STABLA, HALLIE KRISTINA (COTA)
Entity Type:Individual
Prefix:
First Name:HALLIE
Middle Name:KRISTINA
Last Name:STABLA
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 1:1102 OBRIEN ST
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-1841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19395 W CAPITOL DR STE 200
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2736
Practice Address - Country:US
Practice Address - Phone:262-923-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5588-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5588-27OtherWISCONSIN OTA LICENSE