Basic Information
| Provider Information | |||||||||
| NPI: | 1629254537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAFFORD | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 58471 29 PALMS HWY STE 102 | ||||||||
| Address2: | |||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922845818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608534888 | ||||||||
| FaxNumber: | 7604182201 | ||||||||
| Practice Location | |||||||||
| Address1: | 58471 29 PALMS HWY STE 102 | ||||||||
| Address2: | |||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922845818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608534888 | ||||||||
| FaxNumber: | 7604182201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2008 | ||||||||
| LastUpdateDate: | 06/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C21811214 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.