Provider Demographics
NPI:1154523330
Name:SANFORD, STACY (PHD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:SANFORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST
Mailing Address - Street 2:SUITE 21-100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5975
Mailing Address - Country:US
Mailing Address - Phone:312-695-2356
Mailing Address - Fax:312-695-1106
Practice Address - Street 1:675 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 21-100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5975
Practice Address - Country:US
Practice Address - Phone:312-695-2356
Practice Address - Fax:312-695-1106
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2683103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist