Basic Information
| Provider Information | |||||||||
| NPI: | 1104050178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAFFORD | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12550 NEW BRITTANY BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339073655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439190 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12550 NEW BRITTANY BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339073655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439190 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2009 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 111844 | MA | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.