Provider Demographics
NPI:1659969525
Name:STAFFORD, KALEIGH RENEE
Entity Type:Individual
Prefix:
First Name:KALEIGH
Middle Name:RENEE
Last Name:STAFFORD
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 1:108 TAYLORS WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IN
Mailing Address - Zip Code:46554-9224
Mailing Address - Country:US
Mailing Address - Phone:574-360-9996
Mailing Address - Fax:
Practice Address - Street 1:2012 IRONWOOD CIR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1888
Practice Address - Country:US
Practice Address - Phone:574-387-4049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003182A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant