Provider Demographics
NPI:1124459474
Name:STORM, STEPHEN
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:STORM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3028 HIGHWAY 348
Mailing Address - Street 2:
Mailing Address - City:RUDY
Mailing Address - State:AR
Mailing Address - Zip Code:72952-9564
Mailing Address - Country:US
Mailing Address - Phone:479-719-1637
Mailing Address - Fax:
Practice Address - Street 1:3028 HIGHWAY 348
Practice Address - Street 2:
Practice Address - City:RUDY
Practice Address - State:AR
Practice Address - Zip Code:72952-9564
Practice Address - Country:US
Practice Address - Phone:479-719-1637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTA817224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR201121721Medicaid