Provider Demographics
NPI:1346288644
Name:SANDFORT, GRETCHEN LARSON (MPT)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:LARSON
Last Name:SANDFORT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7817 DAKOTA CIR
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-2654
Mailing Address - Country:US
Mailing Address - Phone:515-267-8118
Mailing Address - Fax:
Practice Address - Street 1:6000 UNIVERSITY AVE
Practice Address - Street 2:250
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8203
Practice Address - Country:US
Practice Address - Phone:515-221-1102
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist