Provider Demographics
NPI:1245402296
Name:WALCZAK, STEPHANIE DENICE (COTA/L)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DENICE
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 INDIANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:HENRY
Mailing Address - State:IL
Mailing Address - Zip Code:61537-9227
Mailing Address - Country:US
Mailing Address - Phone:309-364-3905
Mailing Address - Fax:309-364-3567
Practice Address - Street 1:1650 INDIANTOWN RD
Practice Address - Street 2:
Practice Address - City:HENRY
Practice Address - State:IL
Practice Address - Zip Code:61537-9227
Practice Address - Country:US
Practice Address - Phone:309-364-3905
Practice Address - Fax:309-364-3567
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant