Provider Demographics
NPI:1154027035
Name:STAFFORD, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 SUNRISE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:OH
Mailing Address - Zip Code:45693-1143
Mailing Address - Country:US
Mailing Address - Phone:937-544-5547
Mailing Address - Fax:
Practice Address - Street 1:923 SUNRISE AVE
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:OH
Practice Address - Zip Code:45693-1143
Practice Address - Country:US
Practice Address - Phone:937-544-5547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
OH183317101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator