MEDICARE: GINA STORK LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	001715	IA

General Provider Information

NPI Number	:	1801213871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA STORK LMHC

Provider Business Mailing Address
First Line	:	3662 GARBER AVE
Second Line	:
City	:	LAKE CITY
State	:	IA
Zip	:	51449-7554
Country	:	US
Telephone Number	:	712-790-9318
Fax Number	:

Provider Business Practice Location Address
First Line	:	3662 GARBER AVE
Second Line	:
City	:	LAKE CITY
State	:	IA
Zip	:	51449-7554
Country	:	US
Telephone Number	:	712-790-9318
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2014
Last Update Date	:	03/27/2014

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