Provider Demographics
NPI:1053650002
Name:STAFFORD, MAX
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:STAFFORD
Suffix:
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 1:46 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-2544
Mailing Address - Country:US
Mailing Address - Phone:740-851-4432
Mailing Address - Fax:
Practice Address - Street 1:46 E WATER ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2544
Practice Address - Country:US
Practice Address - Phone:740-851-4432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011419101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)