Healthcare Provider Details

I. General information

NPI: 1619063393
Provider Name (Legal Business Name): STEPHAN ROMAN BILAK MPT,PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 30TH AVE SUITE 103
KENOSHA WI
53144
US

IV. Provider business mailing address

3601 30TH AVE SUITE 103
KENOSHA WI
53144
US

V. Phone/Fax

Practice location:
  • Phone: 262-657-7071
  • Fax: 262-657-0632
Mailing address:
  • Phone: 262-657-0222
  • Fax: 262-657-7190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10314-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: