Healthcare Provider Details

I. General information

NPI: 1508180316
Provider Name (Legal Business Name): ANNIE MARIE STAFFORD LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E 78TH ST STE 100
BLOOMINGTON MN
55420-1402
US

IV. Provider business mailing address

1900 SILVER LK RD.
NEW BRIGHTON MN
55112
US

V. Phone/Fax

Practice location:
  • Phone: 529-854-5034
  • Fax: 952-854-5363
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302350
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: