Basic Information
| Provider Information | |||||||||
| NPI: | 1730281403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAFFORD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PH D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 SALEM ROAD | ||||||||
| Address2: | STE 1 | ||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013368300 | ||||||||
| FaxNumber: | 5013293572 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 SALEM ROAD | ||||||||
| Address2: | STE 1 | ||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013368300 | ||||||||
| FaxNumber: | 5013293572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 9823P | AR | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.