MEDICARE: MS. LISA ANN STAFFORD M.ED., LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	4574	OK

General Provider Information

NPI Number	:	1053639971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA ANN STAFFORD M.ED., LPC

Provider Business Mailing Address
First Line	:	31 E 54TH ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-6712
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1843 E 15TH ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74104-4610
Country	:	US
Telephone Number	:	918-712-8800
Fax Number	:	918-712-8802

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2010
Last Update Date	:	06/13/2011

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