Provider Demographics
NPI:1629254537
Name:STAFFORD, STEPHANIE
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
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 1:58471 29 PALMS HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-5818
Mailing Address - Country:US
Mailing Address - Phone:760-853-4888
Mailing Address - Fax:760-418-2201
Practice Address - Street 1:58471 29 PALMS HWY STE 102
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-5818
Practice Address - Country:US
Practice Address - Phone:760-853-4888
Practice Address - Fax:760-418-2201
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC21811214101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)