Provider Demographics
NPI:1801802822
Name:STAUFFER, GARY EDWARD (MSW, ACSW)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:EDWARD
Last Name:STAUFFER
Suffix:
Gender:M
Credentials:MSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2317
Mailing Address - Country:US
Mailing Address - Phone:231-935-0386
Mailing Address - Fax:231-935-0387
Practice Address - Street 1:1213 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2317
Practice Address - Country:US
Practice Address - Phone:231-935-0386
Practice Address - Fax:231-935-0387
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801002634283Q00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No283Q00000XHospitalsPsychiatric Hospital