Provider Demographics
NPI:1659974889
Name:STANFORD, LEAH MARIE
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MARIE
Last Name:STANFORD
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 1:245 N BINKLEY ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7500
Mailing Address - Country:US
Mailing Address - Phone:907-714-4521
Mailing Address - Fax:
Practice Address - Street 1:47480 KRISTINA WAY
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-5902
Practice Address - Country:US
Practice Address - Phone:907-714-4521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1838101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)