Provider Demographics
NPI:1356313225
Name:STORSVED, JOHN RICHARD II (HSD ATC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:STORSVED
Suffix:II
Gender:M
Credentials:HSD ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 S NOTTINGHAM CT
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-7015
Mailing Address - Country:US
Mailing Address - Phone:176-218-7972
Mailing Address - Fax:
Practice Address - Street 1:1184 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62522-2084
Practice Address - Country:US
Practice Address - Phone:217-424-6364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096-0009202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer