Healthcare Provider Details

I. General information

NPI: 1649811035
Provider Name (Legal Business Name): NICHOLAS JOHN STEVENS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 W SAINT GEORGE AVE
GRANTSBURG WI
54840-7827
US

IV. Provider business mailing address

512 235TH AVE
CUMBERLAND WI
54829-9307
US

V. Phone/Fax

Practice location:
  • Phone: 715-463-5353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3003-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: