Provider Demographics
NPI:1710192703
Name:PETTIFORD, SANDRA MARIE (P T)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:MARIE
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:MARIE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:P T
Mailing Address - Street 1:720 GLEN MOR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-3482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1005 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201-1907
Practice Address - Country:US
Practice Address - Phone:618-646-3960
Practice Address - Fax:618-646-3968
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05000547A225100000X
MOR0055225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist