Basic Information
| Provider Information | |||||||||
| NPI: | 1154957108 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STIENESSEN | ||||||||
| FirstName: | ELIANA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | MAOT, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1404 10TH ST SE | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562015421 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2653 COUNTY ROAD 74 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563012205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202294069 | ||||||||
| FaxNumber: | 3202294071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2020 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 106404 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5757 | 01 | MN | OCCUPATIONAL THERAPY PRACTICE LICENSE | OTHER |