Provider Demographics
NPI:1912008186
Name:HANFORD, ANGELA MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:HANFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:POHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:107 CONCORD PLAZA
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-842-2990
Practice Address - Fax:314-842-5162
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103415225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000025280Medicare ID - Type Unspecified