Basic Information
Provider Information | |||||||||
NPI: | 1588016885 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STAFFORD | ||||||||
FirstName: | ANNA-LEE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 83 VALLEY RD APT 2 | ||||||||
Address2: |   | ||||||||
City: | COS COB | ||||||||
State: | CT | ||||||||
PostalCode: | 068072230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2039215464 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 103 W BROAD ST | ||||||||
Address2: |   | ||||||||
City: | STAMFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 069023713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033246127 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2016 | ||||||||
LastUpdateDate: | 09/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X |   |   | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103T00000X | 4289 | CT | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.