Provider Demographics
NPI:1417665308
Name:STAFFORD, TALLIE L (LMSW)
Entity Type:Individual
Prefix:
First Name:TALLIE
Middle Name:L
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-3301
Mailing Address - Country:US
Mailing Address - Phone:417-588-5885
Mailing Address - Fax:
Practice Address - Street 1:104 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3301
Practice Address - Country:US
Practice Address - Phone:417-588-5885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022044555104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker