Healthcare Provider Details

I. General information

NPI: 1255924114
Provider Name (Legal Business Name): LISA A STANFORD LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 SILVERBROOK LN APT B304
OWINGS MILLS MD
21117-6887
US

IV. Provider business mailing address

6912 MAYFAIR TER
LAUREL MD
20707-5211
US

V. Phone/Fax

Practice location:
  • Phone: 240-272-1743
  • Fax:
Mailing address:
  • Phone: 240-272-1743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC200002430
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22178
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904016171
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: