Provider Demographics
NPI:1114580594
Name:STAFFORD, W DAVIDA (AAC, MHP)
Entity type:Individual
Prefix:
First Name:W
Middle Name:DAVIDA
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:AAC, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4245
Mailing Address - Country:US
Mailing Address - Phone:509-899-5512
Mailing Address - Fax:
Practice Address - Street 1:209 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4245
Practice Address - Country:US
Practice Address - Phone:509-899-5512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-21
Last Update Date:2019-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60328778101Y00000X
WA101Y00000X-COUNSELOR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor