Healthcare Provider Details

I. General information

NPI: 1881577633
Provider Name (Legal Business Name): NATHAN WILLIAM STAFFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 SUMMIT AVE
BANGOR ME
04401-5631
US

IV. Provider business mailing address

63 SUMMIT AVE
BANGOR ME
04401-5631
US

V. Phone/Fax

Practice location:
  • Phone: 207-942-3799
  • Fax:
Mailing address:
  • Phone: 605-376-3708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMC24813
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: