Provider Demographics
NPI:1003119918
Name:STAFFORD, DOUGLAS RAY (LPC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:RAY
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9704 S 2760 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-3411
Mailing Address - Country:US
Mailing Address - Phone:801-942-4970
Mailing Address - Fax:
Practice Address - Street 1:411 GRANT ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-2725
Practice Address - Country:US
Practice Address - Phone:801-359-8862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT27743846004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health