Provider Demographics
NPI:1184337495
Name:STAFFORD, JOHN (AMFT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45600 HIGHWAY 79 UNIT 451
Mailing Address - Street 2:
Mailing Address - City:AGUANGA
Mailing Address - State:CA
Mailing Address - Zip Code:92536-6818
Mailing Address - Country:US
Mailing Address - Phone:760-459-4428
Mailing Address - Fax:
Practice Address - Street 1:45525 HIGHWAY 79 # 53
Practice Address - Street 2:
Practice Address - City:AGUANGA
Practice Address - State:CA
Practice Address - Zip Code:92536-8601
Practice Address - Country:US
Practice Address - Phone:760-459-4428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA124898106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
15827578OtherCAQH