Provider Demographics
NPI:1104905934
Name:SANFORD, SUSAN (PT LIC ACC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SANFORD
Suffix:
Gender:F
Credentials:PT LIC ACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 951
Mailing Address - Street 2:
Mailing Address - City:WEST TISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02575-0951
Mailing Address - Country:US
Mailing Address - Phone:508-693-3800
Mailing Address - Fax:508-693-7473
Practice Address - Street 1:238 EDGARTOWN VINEYARD HAVEN ROAD
Practice Address - Street 2:
Practice Address - City:EDGARTOWN
Practice Address - State:MA
Practice Address - Zip Code:02539
Practice Address - Country:US
Practice Address - Phone:508-693-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215639171100000X
CT005094225100000X
MA10886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY68186OtherBLUE CROSS BLUE SHIELD
MAY68186OtherBLUE CROSS BLUE SHIELD