Basic Information
| Provider Information | |||||||||
| NPI: | 1689854689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EWONIUK | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | JANE HARRIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.O.T | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARRIS | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.O.T | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 932 | ||||||||
| Address2: | |||||||||
| City: | THAYNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 831270932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 416 W BLAIR AVE | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829017113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073523626 | ||||||||
| FaxNumber: | 3073523628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2007 | ||||||||
| LastUpdateDate: | 11/07/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT-461 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.