Provider Demographics
NPI:1700966942
Name:GARY D. STANFORTH,LTD.,MSW.,LISW.,LICDC
Entity Type:Organization
Organization Name:GARY D. STANFORTH,LTD.,MSW.,LISW.,LICDC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADDICTIONS/MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:STANFORTH
Authorized Official - Suffix:
Authorized Official - Credentials:LISW, LICDC
Authorized Official - Phone:513-535-7668
Mailing Address - Street 1:9733 DEBOLD KOEBEL RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PLAIN
Mailing Address - State:OH
Mailing Address - Zip Code:45162-9353
Mailing Address - Country:US
Mailing Address - Phone:513-535-7668
Mailing Address - Fax:937-704-0255
Practice Address - Street 1:8401 CLAUDE THOMAS RD
Practice Address - Street 2:SUITE 21 F
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-1497
Practice Address - Country:US
Practice Address - Phone:515-535-7668
Practice Address - Fax:937-704-0255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH06282065OtherMEDICARE PCN