Healthcare Provider Details

I. General information

NPI: 1538703343
Provider Name (Legal Business Name): RANDY STAFFORD MSW, CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S FRONT AVE
PRESTONSBURG KY
41653-1614
US

IV. Provider business mailing address

104 S FRONT AVE
PRESTONSBURG KY
41653-1614
US

V. Phone/Fax

Practice location:
  • Phone: 606-886-8572
  • Fax: 606-884-4433
Mailing address:
  • Phone: 606-886-8572
  • Fax: 606-884-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: