Provider Demographics
NPI:1417083163
Name:STAFFORD, GLYNIS M (MA, LPC, DBTC, NCC)
Entity Type:Individual
Prefix:
First Name:GLYNIS
Middle Name:M
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:MA, LPC, DBTC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 SW GRIFFITH DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-5607
Mailing Address - Country:US
Mailing Address - Phone:503-703-9682
Mailing Address - Fax:971-245-6817
Practice Address - Street 1:4900 SW GRIFFITH DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-5607
Practice Address - Country:US
Practice Address - Phone:503-703-9682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC3055101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC3055OtherLPC
OR81-3036006OtherTAX ID EIN