Provider Demographics
NPI:1821265638
Name:STEVENSON, IDA LYN (COTA/L)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:LYN
Last Name:STEVENSON
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 1:2903 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-2245
Mailing Address - Country:US
Mailing Address - Phone:608-558-6032
Mailing Address - Fax:
Practice Address - Street 1:2903 13TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-2245
Practice Address - Country:US
Practice Address - Phone:608-558-6032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL057003252OtherOCCUPATIONAL THERAPY ASSISTANT LISCENSE
WI1902-27OtherOCCUPATIONAL THERAPY ASSISTANT LISCENSE