Provider Demographics
NPI:1326695610
Name:WALLINGFORD, STEPHEN EDWARD
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EDWARD
Last Name:WALLINGFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-1542
Mailing Address - Country:US
Mailing Address - Phone:740-222-5720
Mailing Address - Fax:
Practice Address - Street 1:2266 WAKEFIELD MOUND RD
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661-9660
Practice Address - Country:US
Practice Address - Phone:740-222-5720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)