Provider Demographics
NPI:1629293105
Name:STAFFORD, KATHY (MS, LBP, LPC)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:MS, LBP, 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 662
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-0662
Mailing Address - Country:US
Mailing Address - Phone:405-527-1785
Mailing Address - Fax:405-527-1084
Practice Address - Street 1:1008 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4734
Practice Address - Country:US
Practice Address - Phone:580-581-1818
Practice Address - Fax:405-527-1819
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1748101YM0800X
OK0018101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health