Provider Demographics
NPI:1164884946
Name:RYAN, STEPHANIE L (DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:RYAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:36500 AURORA DR
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4899
Mailing Address - Country:US
Mailing Address - Phone:262-434-2600
Mailing Address - Fax:
Practice Address - Street 1:36500 AURORA DR
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066-4899
Practice Address - Country:US
Practice Address - Phone:262-434-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12996-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12996-24OtherWISCONSIN PHYSICAL THERAPY LICENSE