Provider Demographics
NPI:1558089987
Name:KSIONDA, STEPHA NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:STEPHA
Middle Name:NICOLE
Last Name:KSIONDA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 S DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-5168
Mailing Address - Country:US
Mailing Address - Phone:520-609-4324
Mailing Address - Fax:
Practice Address - Street 1:115 E ARNDT ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2461
Practice Address - Country:US
Practice Address - Phone:920-923-7879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8028-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist