Provider Demographics
NPI:1891834677
Name:STAFFORD, SANDRA JEAN (LMT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34952 S ELLIS RD
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-8478
Mailing Address - Country:US
Mailing Address - Phone:503-829-5918
Mailing Address - Fax:503-829-2018
Practice Address - Street 1:34952 S ELLIS RD
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-8478
Practice Address - Country:US
Practice Address - Phone:503-829-5918
Practice Address - Fax:503-829-2018
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10643225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10643OtherLMT
OR5980280001Medicare NSC