Provider Demographics
NPI:1184130932
Name:KLINE, STORM MARIA (EDS)
Entity type:Individual
Prefix:MRS
First Name:STORM
Middle Name:MARIA
Last Name:KLINE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N RAYNOR AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6065
Mailing Address - Country:US
Mailing Address - Phone:815-740-3196
Mailing Address - Fax:
Practice Address - Street 1:420 N RAYNOR AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6065
Practice Address - Country:US
Practice Address - Phone:815-740-3196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
IL1109212103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist