Provider Demographics
NPI:1588486013
Name:STANFORD, TASHA ANDREA
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:ANDREA
Last Name:STANFORD
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 1:2616 SW ACACIA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2209
Mailing Address - Country:US
Mailing Address - Phone:772-323-7362
Mailing Address - Fax:
Practice Address - Street 1:4500 W MIDWAY RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-4823
Practice Address - Country:US
Practice Address - Phone:772-672-8466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional