Provider Demographics
NPI:1881148112
Name:STAFFORD, MARSHA KAY (SUDC, LPP)
Entity type:Individual
Prefix:MS
First Name:MARSHA
Middle Name:KAY
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:SUDC, LPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 E 7570 S
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2633
Mailing Address - Country:US
Mailing Address - Phone:801-574-8765
Mailing Address - Fax:
Practice Address - Street 1:76 E 7570 S
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2633
Practice Address - Country:US
Practice Address - Phone:801-574-8765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6300986-6006101YA0400X
UT6300986-5001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT13309154OtherDRIVERS LICENSE