Healthcare Provider Details

I. General information

NPI: 1154286250
Provider Name (Legal Business Name): STEFAN KYLE SANDIFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6443 RIDINGS RD
SYRACUSE NY
13206-1104
US

IV. Provider business mailing address

444 S SALINA ST UNIT 107
SYRACUSE NY
13201-2105
US

V. Phone/Fax

Practice location:
  • Phone: 512-707-9097
  • Fax:
Mailing address:
  • Phone: 512-707-9097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10012190250
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: