Provider Demographics
NPI:1205046968
Name:STAFFORD, MANDY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24759 E US HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:DENNISON
Mailing Address - State:IL
Mailing Address - Zip Code:62423-2710
Mailing Address - Country:US
Mailing Address - Phone:217-822-5135
Mailing Address - Fax:
Practice Address - Street 1:400 W RUSTIC ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1756
Practice Address - Country:US
Practice Address - Phone:618-544-8618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.006848235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist