Provider Demographics
NPI:1528569050
Name:STAFFORD, JOANNA
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 W PROFESSIONAL PARK CT STE 1
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3250
Mailing Address - Country:US
Mailing Address - Phone:270-777-9283
Mailing Address - Fax:270-777-9283
Practice Address - Street 1:3115 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3425
Practice Address - Country:US
Practice Address - Phone:803-791-3722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17-45343106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician