Provider Demographics
NPI:1629611983
Name:STORM, KATHY STORM
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:STORM
Last Name:STORM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3521
Mailing Address - Country:US
Mailing Address - Phone:770-527-5287
Mailing Address - Fax:
Practice Address - Street 1:260 PEACHTREE ST NW STE 2200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-1292
Practice Address - Country:US
Practice Address - Phone:770-527-5287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician