Provider Demographics
NPI:1356900559
Name:STAFFORD, CASSONDA ANNE (LADAC)
Entity type:Individual
Prefix:MRS
First Name:CASSONDA
Middle Name:ANNE
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 S ATKINSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-7154
Mailing Address - Country:US
Mailing Address - Phone:575-578-4826
Mailing Address - Fax:
Practice Address - Street 1:1107 S ATKINSON AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-7154
Practice Address - Country:US
Practice Address - Phone:575-578-4826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCAD0196841101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM05Medicaid