Provider Demographics
NPI:1528266038
Name:STANFORD, CARYN KAY (PT)
Entity type:Individual
Prefix:MRS
First Name:CARYN
Middle Name:KAY
Last Name:STANFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MR
Other - First Name:CARYN
Other - Middle Name:KAY
Other - Last Name:HEISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8261 WALDORA RD
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-8759
Mailing Address - Country:US
Mailing Address - Phone:715-349-8757
Mailing Address - Fax:
Practice Address - Street 1:2448 S 102ND ST
Practice Address - Street 2:SUITE 340
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2466
Practice Address - Country:US
Practice Address - Phone:414-329-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5291-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist