Provider Demographics
NPI:1275789885
Name:STORK, SANDRA L (RC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:STORK
Suffix:
Gender:F
Credentials:RC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:WA
Mailing Address - Zip Code:98244-0157
Mailing Address - Country:US
Mailing Address - Phone:360-966-2106
Mailing Address - Fax:360-966-7227
Practice Address - Street 1:6760 MISSION RD
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-9749
Practice Address - Country:US
Practice Address - Phone:360-966-2106
Practice Address - Fax:360-966-7227
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00013533101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1981018Medicaid