Provider Demographics
NPI:1629650411
Name:STAFFORD, ALYSSA ANN
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ANN
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:OCTOBER
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6836 ISAAC'S ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762
Mailing Address - Country:US
Mailing Address - Phone:479-927-4100
Mailing Address - Fax:479-927-4101
Practice Address - Street 1:6836 ISAAC'S ORCHARD RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762
Practice Address - Country:US
Practice Address - Phone:479-927-4100
Practice Address - Fax:479-927-4101
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR262527706Medicaid