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NPI Code Detail

MEDICARE: MR. MARK JUDE STANFORD LCSW

MEDICARE: MR. MARK JUDE STANFORD LCSW
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
11041C0700XClinical Social Worker10658LA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
110658OTHERLALCSW LICENSE #

General Provider Information

NPI Number : 1073879649
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MARK JUDE STANFORD LCSW
Provider Business Mailing Address
First Line : 112 HOWARD AVE
Second Line :
City : LAFAYETTE
State : LA
Zip : 70506-4402
Country : US
Telephone Number : 337-344-1617
Fax Number : 337-289-9336
Provider Business Practice Location Address
First Line : 1003 HUGH WALLIS RD S
Second Line : C-6
City : LAFAYETTE
State : LA
Zip : 70508-2528
Country : US
Telephone Number : 337-344-1617
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/07/2012
Last Update Date : 04/07/2012

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