Provider Demographics
NPI:1902305402
Name:BUFORD, STAN DWANE (MS, NCC, PLCP, EMDR)
Entity type:Individual
Prefix:MR
First Name:STAN
Middle Name:DWANE
Last Name:BUFORD
Suffix:
Gender:M
Credentials:MS, NCC, PLCP, EMDR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4236 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-1617
Mailing Address - Country:US
Mailing Address - Phone:417-496-6062
Mailing Address - Fax:417-882-6787
Practice Address - Street 1:3734 SOUTH AVE STE C
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5291
Practice Address - Country:US
Practice Address - Phone:417-882-6767
Practice Address - Fax:417-882-6787
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016028726101YM0800X, 101YP2500X, 106H00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist