Provider Demographics
NPI:1497809040
Name:STAFFORD, PHILLIP (LCSW)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:STAFFORD
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 1:3080 ROYAL OAK DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-4815
Mailing Address - Country:US
Mailing Address - Phone:407-435-2907
Mailing Address - Fax:
Practice Address - Street 1:3080 ROYAL OAK DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-4815
Practice Address - Country:US
Practice Address - Phone:407-435-2907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL177621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical