Provider Demographics
NPI:1851956536
Name:STORM, VIVIAN LOUISE (OTR)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:LOUISE
Last Name:STORM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1394 RED OAKS DR
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-2156
Mailing Address - Country:US
Mailing Address - Phone:608-787-0208
Mailing Address - Fax:
Practice Address - Street 1:1500 GREEN BAY ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6455
Practice Address - Country:US
Practice Address - Phone:608-784-8125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1359-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist