Provider Demographics
NPI:1558777565
Name:STEVENS, IAN S
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:S
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 HAWKS RIDGE DR
Mailing Address - Street 2:APT 201
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-8511
Mailing Address - Country:US
Mailing Address - Phone:815-233-2400
Mailing Address - Fax:815-233-9272
Practice Address - Street 1:2170 W NAVAJO DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-0010
Practice Address - Country:US
Practice Address - Phone:815-233-2400
Practice Address - Fax:815-233-9272
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.010403225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056.010403OtherSTATE LICENSE