Healthcare Provider Details

I. General information

NPI: 1790990430
Provider Name (Legal Business Name): JAMES DOUGLAS STAFFORD ACSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41647 HIGHWAY 315
BATESVILLE MS
38606-8353
US

IV. Provider business mailing address

41647 HIGHWAY 315
BATESVILLE MS
38606-8353
US

V. Phone/Fax

Practice location:
  • Phone: 662-609-1836
  • Fax: 662-915-6917
Mailing address:
  • Phone: 662-609-1836
  • Fax: 662-915-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC0780
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: