Provider Demographics
NPI:1598209132
Name:STAFFORD, KEVIN SEAN (LICSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:SEAN
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10230 PRINCE PL APT 208
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1223
Mailing Address - Country:US
Mailing Address - Phone:202-813-5661
Mailing Address - Fax:
Practice Address - Street 1:2415 RANDOLPH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-3135
Practice Address - Country:US
Practice Address - Phone:202-813-5661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-16
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG500805731041S0200X
DCLC200002128104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool