Provider Demographics
NPI:1962016832
Name:STAFFORD, CHARLES DOUGLAS (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10085 CORRAL RIVER CT
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6812
Mailing Address - Country:US
Mailing Address - Phone:714-861-9044
Mailing Address - Fax:
Practice Address - Street 1:1300 N BRISTOL ST STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2989
Practice Address - Country:US
Practice Address - Phone:714-861-9044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA967301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical