Provider Demographics
NPI:1629628748
Name:STRUCK, STEPHANIE (OTR)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:STRUCK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2302
Mailing Address - Country:US
Mailing Address - Phone:701-403-3765
Mailing Address - Fax:
Practice Address - Street 1:4674 40TH AVE S STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4501
Practice Address - Country:US
Practice Address - Phone:701-293-7294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
427296225X00000X
ND1713225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA