Provider Demographics
NPI:1699047555
Name:STORM, VICTORIA A (MT-BC)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:A
Last Name:STORM
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 N HARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2336
Mailing Address - Country:US
Mailing Address - Phone:312-286-6778
Mailing Address - Fax:708-445-8568
Practice Address - Street 1:427 N HARVEY AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2336
Practice Address - Country:US
Practice Address - Phone:312-286-6778
Practice Address - Fax:708-445-8568
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05097225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist