Provider Demographics
NPI:1942627963
Name:STORK, JOSHUA (ATC, LAT, MBA)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:STORK
Suffix:
Gender:M
Credentials:ATC, LAT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11130 PARKVIEW CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1735
Mailing Address - Country:US
Mailing Address - Phone:260-249-9534
Mailing Address - Fax:
Practice Address - Street 1:3601 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-2006
Practice Address - Country:US
Practice Address - Phone:260-249-9534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001441A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer