Provider Demographics
NPI:1316286479
Name:WALLINGSFORD, SARAH JANE
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:JANE
Last Name:WALLINGSFORD
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 1:826 WOOLWICK CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-6944
Mailing Address - Country:US
Mailing Address - Phone:636-928-2165
Mailing Address - Fax:
Practice Address - Street 1:853 MEDICAL DR STE 109
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3825
Practice Address - Country:US
Practice Address - Phone:636-327-7240
Practice Address - Fax:636-327-7249
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013004057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist