Provider Demographics
NPI:1073971081
Name:TOWN OF STAFFORD
Entity Type:Organization
Organization Name:TOWN OF STAFFORD
Other - Org Name:STAFFORD FAMILY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:860-684-4239
Mailing Address - Street 1:21 HYDE PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076-1507
Mailing Address - Country:US
Mailing Address - Phone:860-684-4239
Mailing Address - Fax:860-684-0511
Practice Address - Street 1:21 HYDE PARK RD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-1507
Practice Address - Country:US
Practice Address - Phone:860-684-4239
Practice Address - Fax:860-684-0511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTOPCC 77251S00000X
CT0605251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008032687Medicaid