Provider Demographics
NPI:1013185081
Name:STORK, TRISHA MARIE (COTA)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:MARIE
Last Name:STORK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:MARIE
Other - Last Name:DENUCCI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:708 RYAN RONALD RD
Mailing Address - City:ROBERTS
Mailing Address - State:WI
Mailing Address - Zip Code:54023-0002
Mailing Address - Country:US
Mailing Address - Phone:715-749-4473
Mailing Address - Fax:
Practice Address - Street 1:2705 ENLOE ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8173
Practice Address - Country:US
Practice Address - Phone:715-386-2128
Practice Address - Fax:715-386-6119
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4588224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant