Provider Demographics
NPI:1104050178
Name:STAFFORD, LAURA ANN (LICSW)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANN
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12550 NEW BRITTANY BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3655
Mailing Address - Country:US
Mailing Address - Phone:239-343-9190
Mailing Address - Fax:
Practice Address - Street 1:12550 NEW BRITTANY BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3655
Practice Address - Country:US
Practice Address - Phone:239-343-9190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111844322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children