Provider Demographics
NPI:1689847139
Name:STEFANICH, DAVID C (LPTA)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:C
Last Name:STEFANICH
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N9480 COUNTY ROAD B
Mailing Address - Street 2:
Mailing Address - City:SUMMIT LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54485-9776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N9480 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:SUMMIT LAKE
Practice Address - State:WI
Practice Address - Zip Code:54485-9776
Practice Address - Country:US
Practice Address - Phone:715-275-3118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1062019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant