Provider Demographics
NPI:1194292334
Name:STORK, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:STORK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:389 ILLINI DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:IL
Mailing Address - Zip Code:61565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:807 W COLUMBIA TERRACE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606
Practice Address - Country:US
Practice Address - Phone:309-682-2693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist