Basic Information
| Provider Information | |||||||||
| NPI: | 1326205741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEARY | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | K. | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON, THORSON | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 880 INDEPENDENCE LN | ||||||||
| Address2: | |||||||||
| City: | SAUK CITY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535831381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086432343 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 880 INDEPENDENCE LN | ||||||||
| Address2: | |||||||||
| City: | SAUK CITY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535831381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086432343 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 11/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10988-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 36165600 | 05 | WI | MEDICAID |