Provider Demographics
NPI:1285711911
Name:SANFORD, HEIDI SHIRENE
Entity type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:SHIRENE
Last Name:SANFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14971 WILBUR RD
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257
Mailing Address - Country:US
Mailing Address - Phone:360-466-0270
Mailing Address - Fax:360-466-0270
Practice Address - Street 1:315 MAIN ST
Practice Address - Street 2:SUITE A1
Practice Address - City:MT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2314
Practice Address - Country:US
Practice Address - Phone:360-336-3432
Practice Address - Fax:360-336-3492
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0229998225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist