Provider Demographics
NPI:1366500472
Name:STORCK, BETHANY ELLEN (ATC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ELLEN
Last Name:STORCK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 WILSON RD
Mailing Address - Street 2:APARTMENT 431
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-6033
Mailing Address - Country:US
Mailing Address - Phone:203-417-6782
Mailing Address - Fax:
Practice Address - Street 1:117 STOKELY ATHLETIC CTR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37996-0001
Practice Address - Country:US
Practice Address - Phone:865-974-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2008-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3272255A2300X
TN11192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH060602170OtherBOC CERTIFICATION NUMBER