Provider Demographics
NPI:1235272154
Name:MARTIN-STANFORD, TASHA
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:MARTIN-STANFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 QUEEN RIDGE AVE
Mailing Address - Street 2:APT 732
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64136-1423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4820 QUEEN RIDGE AVE
Practice Address - Street 2:APT 732
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64136-1423
Practice Address - Country:US
Practice Address - Phone:816-373-4841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116968235Z00000X
KS01850235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO464777424Medicaid