Healthcare Provider Details

I. General information

NPI: 1568375715
Provider Name (Legal Business Name): STEPHANIE MULLIS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N2460 COUNTY ROAD O
DELAVAN WI
53115-3112
US

IV. Provider business mailing address

341 BRADLEY AVE
DELAVAN WI
53115-1923
US

V. Phone/Fax

Practice location:
  • Phone: 262-374-5199
  • Fax:
Mailing address:
  • Phone: 608-746-0033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number10510146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: