Healthcare Provider Details

I. General information

NPI: 1053114439
Provider Name (Legal Business Name): STEPHANIE DIANA OWSIAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-9100
  • Fax:
Mailing address:
  • Phone: 708-783-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041487493
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: