Basic Information
Provider Information | |||||||||
NPI: | 1962665323 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STELSON | ||||||||
FirstName: | DENISE | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | COTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BARTELS | ||||||||
OtherFirstName: | DENISE | ||||||||
OtherMiddleName: | RENEE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1436 SOUTH LINCOLN STREET | ||||||||
Address2: |   | ||||||||
City: | SHAWANO | ||||||||
State: | WI | ||||||||
PostalCode: | 54166 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7155266111 | ||||||||
FaxNumber: | 7155245708 | ||||||||
Practice Location | |||||||||
Address1: | 3360 GATEWAY RD STE 100 | ||||||||
Address2: |   | ||||||||
City: | BROOKFIELD | ||||||||
State: | WI | ||||||||
PostalCode: | 530455115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2629237171 | ||||||||
FaxNumber: | 2629237178 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2008 | ||||||||
LastUpdateDate: | 09/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 839027 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 40797400 | 05 | WI |   | MEDICAID |