Provider Demographics
NPI:1245599661
Name:BRUCE L. STAFFORD, PA
Entity Type:Organization
Organization Name:BRUCE L. STAFFORD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LILCENSED CLINICAL SOCAIL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:407-648-9118
Mailing Address - Street 1:631 N HYER AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4629
Mailing Address - Country:US
Mailing Address - Phone:407-648-9118
Mailing Address - Fax:407-865-5432
Practice Address - Street 1:631 N HYER AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-4629
Practice Address - Country:US
Practice Address - Phone:407-648-9118
Practice Address - Fax:407-865-5432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW16181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty