Provider Demographics
NPI:1184021909
Name:STORCH, WANDA (PT)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:
Last Name:STORCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 LONGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:STELLA
Mailing Address - State:NC
Mailing Address - Zip Code:28582-9671
Mailing Address - Country:US
Mailing Address - Phone:910-687-4676
Mailing Address - Fax:
Practice Address - Street 1:138 LONGWOOD DR
Practice Address - Street 2:
Practice Address - City:STELLA
Practice Address - State:NC
Practice Address - Zip Code:28582-9671
Practice Address - Country:US
Practice Address - Phone:910-687-4676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP2836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP2836OtherPT LICENSE