Provider Demographics
NPI:1407607369
Name:STAFFORD, NICOLE RENE J (MSW, CSWA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RENE J
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:MSW, CSWA
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:RENE J
Other - Last Name:LACASSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:582 GLENGARY LOOP RD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-8442
Mailing Address - Country:US
Mailing Address - Phone:425-870-2523
Mailing Address - Fax:
Practice Address - Street 1:2001 NW NEWCASTLE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1657
Practice Address - Country:US
Practice Address - Phone:541-492-2087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA150381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical