Provider Demographics
NPI:1013188101
Name:STAFFORD, LISA P (MS,CSP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:P
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:MS,CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SISTERSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:WV
Mailing Address - Zip Code:26456-1034
Mailing Address - Country:US
Mailing Address - Phone:304-624-6554
Mailing Address - Fax:304-624-5223
Practice Address - Street 1:104 SISTERSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:WV
Practice Address - Zip Code:26456-1034
Practice Address - Country:US
Practice Address - Phone:304-624-6554
Practice Address - Fax:304-624-5223
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11106103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0166396000Medicaid