Healthcare Provider Details

I. General information

NPI: 1801802822
Provider Name (Legal Business Name): GARY EDWARD STAUFFER M.S.W., A.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 W FRONT ST
TRAVERSE CITY MI
49684-2317
US

IV. Provider business mailing address

1213 W FRONT ST
TRAVERSE CITY MI
49684-2317
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0386
  • Fax: 231-935-0387
Mailing address:
  • Phone: 231-935-0386
  • Fax: 231-935-0387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number6801002634
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801002634
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: