Provider Demographics
NPI:1578833521
Name:STAFFORD, KELLY LOGAN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LOGAN
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:LPC
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 2582
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-2582
Mailing Address - Country:US
Mailing Address - Phone:601-573-7908
Mailing Address - Fax:601-510-9356
Practice Address - Street 1:357 TOWNE CENTER PL
Practice Address - Street 2:SUITE 402
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4870
Practice Address - Country:US
Practice Address - Phone:601-573-7908
Practice Address - Fax:601-510-9356
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1320101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional