Healthcare Provider Details

I. General information

NPI: 1730788217
Provider Name (Legal Business Name): TARA CHRISTINE STAFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CARLYLE CT
DANVILLE CA
94506-6147
US

IV. Provider business mailing address

135 PINELAWN RD STE 204N
MELVILLE NY
11747-3133
US

V. Phone/Fax

Practice location:
  • Phone: 925-980-0961
  • Fax:
Mailing address:
  • Phone: 844-888-0355
  • Fax: 844-888-4005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: