Basic Information
| Provider Information | |||||||||
| NPI: | 1528266038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANFORD | ||||||||
| FirstName: | CARYN | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEISE | ||||||||
| OtherFirstName: | CARYN | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8261 WALDORA RD | ||||||||
| Address2: | |||||||||
| City: | SIREN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548728759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153498757 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2448 S 102ND ST | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532272466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143292500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5291-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.