Provider Demographics
NPI:1689704660
Name:DEFORD, SANDI GREENE (MS)
Entity Type:Individual
Prefix:MRS
First Name:SANDI
Middle Name:GREENE
Last Name:DEFORD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2670
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-647-9762
Practice Address - Street 1:175 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2670
Practice Address - Country:US
Practice Address - Phone:309-647-0201
Practice Address - Fax:309-647-9762
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000582231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
203356810OtherTAX ID