Provider Demographics
NPI:1851915102
Name:ACEVEDO-THOMAS, STEFANIE (PTA)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:ACEVEDO-THOMAS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:
Other - Last Name:ACEVEDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:2999 N MAYFAIR RD STE 300
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4306
Practice Address - Country:US
Practice Address - Phone:414-479-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16841-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100281964Medicaid