Provider Demographics
NPI:1700668092
Name:STANFORD, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:STANFORD
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 1:555 STOCKTON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-2534
Mailing Address - Country:US
Mailing Address - Phone:904-387-4661
Mailing Address - Fax:904-361-5005
Practice Address - Street 1:555 STOCKTON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-2534
Practice Address - Country:US
Practice Address - Phone:904-387-4661
Practice Address - Fax:904-361-5005
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor