Provider Demographics
NPI:1699104240
Name:STAFFORD, MARK (BCBA,LPA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:BCBA,LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W NC HIGHWAY 54 BYP
Mailing Address - Street 2:APT. 40
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-2817
Mailing Address - Country:US
Mailing Address - Phone:919-636-1948
Mailing Address - Fax:
Practice Address - Street 1:1100 W NC HIGHWAY 54 BYP
Practice Address - Street 2:APT. 40
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516-2817
Practice Address - Country:US
Practice Address - Phone:919-636-1948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NC1492103TM1800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist