Healthcare Provider Details

I. General information

NPI: 1952823676
Provider Name (Legal Business Name): ELIZABETH DESIREE FORGEY STAFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 PROVIDENCE RD STE 80
VIRGINIA BEACH VA
23464-4128
US

IV. Provider business mailing address

4668 PEMBROKE BLVD STE 115
VIRGINIA BEACH VA
23455-6423
US

V. Phone/Fax

Practice location:
  • Phone: 757-467-4604
  • Fax: 757-467-2716
Mailing address:
  • Phone: 757-648-8562
  • Fax: 757-648-8564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202008633
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP101230
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP013037
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: