Provider Demographics
NPI:1700594488
Name:STAFFORD, NICHOLAS (CPRS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 PEMBERTON BROWNS MILLS RD
Mailing Address - Street 2:
Mailing Address - City:PEMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08068-1537
Mailing Address - Country:US
Mailing Address - Phone:609-321-6269
Mailing Address - Fax:
Practice Address - Street 1:610 PEMBERTON BROWNS MILLS RD
Practice Address - Street 2:
Practice Address - City:PEMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08068-1537
Practice Address - Country:US
Practice Address - Phone:609-321-6269
Practice Address - Fax:609-283-0262
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1000140324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1000140OtherSUBSTANCE ABUSE REHABILITATION FACILITY