MEDICARE: DESERIE STANFORD

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1902739139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESERIE STANFORD

Provider Business Mailing Address
First Line	:	9314 RYDER DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78254-2000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15140 BADGER RANCH BLVD
Second Line	:
City	:	WOODWAY
State	:	TX
Zip	:	76712-8983
Country	:	US
Telephone Number	:	254-545-2674
Fax Number	:

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

Provider Enumeration Date	:	06/06/2026
Last Update Date	:	06/06/2026

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Directions to “ DESERIE STANFORD ” Practice Location

Language	Start Address	Practice Location

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