Provider Demographics
NPI:1265064430
Name:STAFFAN, LORIE
Entity type:Individual
Prefix:MS
First Name:LORIE
Middle Name:
Last Name:STAFFAN
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 1:1122 N PLUM ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2146
Mailing Address - Country:US
Mailing Address - Phone:937-926-2026
Mailing Address - Fax:
Practice Address - Street 1:1411 N FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2637
Practice Address - Country:US
Practice Address - Phone:937-426-2686
Practice Address - Fax:937-426-6230
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.216628163W00000X
OHC.2304846-TRNE390200000X
OHC2406188101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program