Provider Demographics
NPI:1447563481
Name:STANFORD, IRIS (DPT)
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:
Last Name:STANFORD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3303
Mailing Address - Country:US
Mailing Address - Phone:770-832-2484
Mailing Address - Fax:770-830-5961
Practice Address - Street 1:812 S PARK ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4412
Practice Address - Country:US
Practice Address - Phone:770-834-7436
Practice Address - Fax:770-830-5954
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009969225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist