Provider Demographics
NPI:1396701355
Name:STANFORD, MARY S (PT, OCS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:STANFORD
Suffix:
Gender:F
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1928
Mailing Address - Street 2:
Mailing Address - City:BLUE JAY
Mailing Address - State:CA
Mailing Address - Zip Code:92317-1928
Mailing Address - Country:US
Mailing Address - Phone:909-866-6202
Mailing Address - Fax:909-866-6203
Practice Address - Street 1:42007 FOX FARM RD.
Practice Address - Street 2:SUITE #2
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315
Practice Address - Country:US
Practice Address - Phone:909-866-6202
Practice Address - Fax:909-866-6203
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT193012251E1200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT193010Medicare ID - Type UnspecifiedP.T. PROVIDER NUMBER