Provider Demographics
NPI:1417168329
Name:STANDIFORD, RICHARD A (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:A
Last Name:STANDIFORD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 1ST STREET SE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-9353
Mailing Address - Country:US
Mailing Address - Phone:541-347-2529
Mailing Address - Fax:541-347-9196
Practice Address - Street 1:1010 1ST STREET SE
Practice Address - Street 2:SUITE 110
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9353
Practice Address - Country:US
Practice Address - Phone:541-347-2529
Practice Address - Fax:541-347-9196
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL54001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health