Healthcare Provider Details

I. General information

NPI: 1275103368
Provider Name (Legal Business Name): STEPHANIE A BANDURA PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 N DOWNER AVE
MILWAUKEE WI
53211-4245
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 414-962-4400
  • Fax: 414-962-5674
Mailing address:
  • Phone: 630-575-1980
  • Fax: 630-928-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15404-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: