Provider Demographics
NPI:1083924591
Name:STAFFORD, PAMELA KRISTIN (MA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:KRISTIN
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 SAINT ANDREWS RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-3143
Mailing Address - Country:US
Mailing Address - Phone:505-235-3453
Mailing Address - Fax:
Practice Address - Street 1:6334 SAINT ANDREWS RD
Practice Address - Street 2:SUITE 204
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-3143
Practice Address - Country:US
Practice Address - Phone:505-235-3453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0134811101YM0800X
SC5564101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1305Medicaid