Provider Demographics
NPI:1679813984
Name:STAFFORD, ERICH
Entity Type:Individual
Prefix:
First Name:ERICH
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-1230
Mailing Address - Country:US
Mailing Address - Phone:409-673-7914
Mailing Address - Fax:
Practice Address - Street 1:2 OLD NEW MILFORD RD
Practice Address - Street 2:SUITE 1B
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-2426
Practice Address - Country:US
Practice Address - Phone:409-673-7914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002284101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor