Provider Demographics
NPI:1295112340
Name:STOLLBERG, JOHN EVAN (OTD, OTR/L, CHT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EVAN
Last Name:STOLLBERG
Suffix:
Gender:M
Credentials:OTD, OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 S LAKEPORT ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4222
Mailing Address - Country:US
Mailing Address - Phone:712-277-4442
Mailing Address - Fax:712-202-0578
Practice Address - Street 1:3100 S LAKEPORT ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4222
Practice Address - Country:US
Practice Address - Phone:712-277-4442
Practice Address - Fax:712-202-0578
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101897225X00000X
KS17-03060225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist