Basic Information
| Provider Information | |||||||||
| NPI: | 1013213578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | SOPHIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUTBROD | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | SOPHIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 855 N WESTHAVEN DR | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204567000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3151 EDEN CT | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549046639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206514000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2011 | ||||||||
| LastUpdateDate: | 07/01/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 4981-26 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.