Provider Demographics
NPI:1073879649
Name:STANFORD, MARK JUDE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:JUDE
Last Name:STANFORD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4402
Mailing Address - Country:US
Mailing Address - Phone:337-344-1617
Mailing Address - Fax:337-289-9336
Practice Address - Street 1:1003 HUGH WALLIS RD S
Practice Address - Street 2:C-6
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-2528
Practice Address - Country:US
Practice Address - Phone:337-344-1617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-07
Last Update Date:2012-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA106581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA10658OtherLCSW LICENSE #