Healthcare Provider Details

I. General information

NPI: 1043199979
Provider Name (Legal Business Name): KATHERINE STAFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2737 YOUNGSTOWN RD SE
WARREN OH
44484-5002
US

IV. Provider business mailing address

2737 YOUNGSTOWN RD SE
WARREN OH
44484-5002
US

V. Phone/Fax

Practice location:
  • Phone: 330-369-8022
  • Fax:
Mailing address:
  • Phone: 330-369-8022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.194775
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2504458-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: