MEDICARE: STANFORD PURNELL III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1071396	ID
2	1041C0700X	Clinical Social Worker	SW20454	FL

General Provider Information

NPI Number	:	1053051441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STANFORD PURNELL III

Provider Business Mailing Address
First Line	:	1145 AUDACE AVE APT 304
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-3484
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1145 AUDACE AVE APT 304
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-3484
Country	:	US
Telephone Number	:	561-281-5828
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2022
Last Update Date	:	12/24/2025

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