Provider Demographics
NPI:1346667417
Name:STAFFORD, CYNTHIA (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 WILLIAMSBURG AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-1128
Mailing Address - Country:US
Mailing Address - Phone:630-262-2640
Mailing Address - Fax:
Practice Address - Street 1:2631 WILLIAMSBURG AVE STE 302
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-1128
Practice Address - Country:US
Practice Address - Phone:630-262-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.001516101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional