Provider Demographics
NPI:1619063393
Name:BILAK, STEPHAN ROMAN (MPT,PHD)
Entity type:Individual
Prefix:
First Name:STEPHAN
Middle Name:ROMAN
Last Name:BILAK
Suffix:
Gender:M
Credentials:MPT,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 30TH AVE SUITE 103
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144
Mailing Address - Country:US
Mailing Address - Phone:262-657-0222
Mailing Address - Fax:262-657-7190
Practice Address - Street 1:3601 30TH AVE SUITE 103
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144
Practice Address - Country:US
Practice Address - Phone:262-657-7071
Practice Address - Fax:262-657-0632
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10314-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40445900Medicaid