Basic Information
| Provider Information | |||||||||
| NPI: | 1659974889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANFORD | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 N BINKLEY ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996697500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077144521 | ||||||||
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| Practice Location | |||||||||
| Address1: | 47480 KRISTINA WAY | ||||||||
| Address2: | |||||||||
| City: | KENAI | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996115902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077144521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2020 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1838 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.