Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor | 27743846004 | UT |
NPI | 1003119918 |
---|---|
Provider Name | Douglas Ray Stafford |
First Address | Sandy, UT 84092-3411 |
Second Address | Salt Lake City, UT 84116-2725 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2010 |
Last Update Date | 15/12/2010 |