Provider Demographics
NPI:1508277484
Name:STAFFORD, KELLIE A (LSW)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:A
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:664 SLATE AVENUE
Practice Address - Street 2:
Practice Address - City:OWINGSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40360
Practice Address - Country:US
Practice Address - Phone:606-674-6690
Practice Address - Fax:606-674-3005
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2271104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid