Provider Demographics
NPI:1619349883
Name:STORK, BRANDY L (HIS)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:L
Last Name:STORK
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 WASHINGTON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4238
Mailing Address - Country:US
Mailing Address - Phone:262-637-5668
Mailing Address - Fax:262-637-5009
Practice Address - Street 1:5027 GREEN BAY RD
Practice Address - Street 2:SUITE 104
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1771
Practice Address - Country:US
Practice Address - Phone:262-657-5350
Practice Address - Fax:262-764-0598
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1473237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist