Provider Demographics
NPI:1013395052
Name:STANFORD, LEROY JR
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:STANFORD
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 MOUNT EPHRAIM AVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08104-3236
Mailing Address - Country:US
Mailing Address - Phone:856-963-7323
Mailing Address - Fax:856-963-7324
Practice Address - Street 1:2600 MOUNT EPHRAIM AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08104-3236
Practice Address - Country:US
Practice Address - Phone:856-963-7323
Practice Address - Fax:856-963-7324
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00215600101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)