Provider Demographics
NPI:1528263340
Name:STAFFORD, MATT SCOTT (LCSW)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:SCOTT
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 THORAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-1227
Mailing Address - Country:US
Mailing Address - Phone:210-316-5040
Mailing Address - Fax:210-348-8990
Practice Address - Street 1:117 SOUTHBRIDGE ST
Practice Address - Street 2:STE 303
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6229
Practice Address - Country:US
Practice Address - Phone:210-316-5040
Practice Address - Fax:210-348-8990
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX364461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX36446OtherTX LCSW LICENSE #