Provider Demographics
NPI:1477162022
Name:DEIS, STEPHANIE GLORIA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GLORIA
Last Name:DEIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 OKEEFFE AVE APT 113
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-4229
Mailing Address - Country:US
Mailing Address - Phone:612-309-2062
Mailing Address - Fax:
Practice Address - Street 1:1330 OKEEFFE AVE APT 113
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-4229
Practice Address - Country:US
Practice Address - Phone:612-309-2062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6721-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6721-26OtherSTATE OF WISCONSIN
435982OtherNBCOT