Provider Demographics
NPI:1649507369
Name:STAFFORD, CHARLES N
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:N
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4006 ANGELINA LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-3133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4006 ANGELINA LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95212-3133
Practice Address - Country:US
Practice Address - Phone:209-808-3109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor