Provider Demographics
NPI:1558697136
Name:STOPFORTH, MARINDA
Entity Type:Individual
Prefix:MRS
First Name:MARINDA
Middle Name:
Last Name:STOPFORTH
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 1:120 OSLER
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-7429
Mailing Address - Country:US
Mailing Address - Phone:630-527-3375
Mailing Address - Fax:630-527-3380
Practice Address - Street 1:120 OSLER
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-7429
Practice Address - Country:US
Practice Address - Phone:630-527-3375
Practice Address - Fax:630-527-3380
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL56006845225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363297173001Medicaid
140231Medicare PIN