Provider Demographics
NPI:1679133102
Name:STAFFORD, JOANN C
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:C
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3417
Mailing Address - Country:US
Mailing Address - Phone:914-666-1200
Mailing Address - Fax:
Practice Address - Street 1:400 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-3417
Practice Address - Country:US
Practice Address - Phone:914-666-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009354-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY009354-1OtherTHE UNIVERSITY OF THE STATE OF NEW YORK EDUCATION DEPARTMENT