Provider Demographics
NPI:1316438963
Name:STORM, CHELSEA RENAE
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:RENAE
Last Name:STORM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2044 N US HIGHWAY 45
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:IL
Mailing Address - Zip Code:62443-2903
Mailing Address - Country:US
Mailing Address - Phone:217-690-3537
Mailing Address - Fax:
Practice Address - Street 1:1111 W NORTH 12TH ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-9554
Practice Address - Country:US
Practice Address - Phone:217-774-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007889225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant