Provider Demographics
NPI:1770012320
Name:STANFORD, CHARLIE JR (MS, LMHCA)
Entity Type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:STANFORD
Suffix:JR
Gender:M
Credentials:MS, LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 COLUMBIA AVE STE 151
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4347
Mailing Address - Country:US
Mailing Address - Phone:253-269-0224
Mailing Address - Fax:360-386-9519
Practice Address - Street 1:1106 COLUMBIA AVE STE 151
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4347
Practice Address - Country:US
Practice Address - Phone:253-269-0224
Practice Address - Fax:253-833-8850
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60699756101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health