Basic Information
| Provider Information | |||||||||
| NPI: | 1306011283 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAFFORD | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28000 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480922468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867530400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 243 LAKEWOOD ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482153151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134209537 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2008 | ||||||||
| LastUpdateDate: | 06/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401010739 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.