Provider Demographics
NPI:1275276701
Name:STAFFORD, SAMANTHA (DPT)
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 W SPRINGFIELD AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-3098
Mailing Address - Country:US
Mailing Address - Phone:217-898-8393
Mailing Address - Fax:217-633-4553
Practice Address - Street 1:1907 W SPRINGFIELD AVE STE B
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-3098
Practice Address - Country:US
Practice Address - Phone:217-898-8393
Practice Address - Fax:217-633-4553
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist