Provider Demographics
NPI:1316489578
Name:OLESTON, STEPHANIE (LATC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:OLESTON
Suffix:
Gender:F
Credentials:LATC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LATC
Mailing Address - Street 1:11033 S STATE ROAD 140
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WI
Mailing Address - Zip Code:53525-8442
Mailing Address - Country:US
Mailing Address - Phone:815-762-4468
Mailing Address - Fax:
Practice Address - Street 1:5510 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2381
Practice Address - Country:US
Practice Address - Phone:815-762-4468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960031852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL096003185OtherILLINOIS STATE LICENSE
IL2000007667OtherCERTIFICATION NUMBER