MEDICARE: STAFFORD SERVICES OF COASTAL GEORGIA LLC

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1104619329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STAFFORD SERVICES OF COASTAL GEORGIA LLC

Provider Business Mailing Address
First Line	:	PO BOX 1943
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-1943
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	185 RICHARD DAVIS DR STE 105
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-3978
Country	:	US
Telephone Number	:	833-779-3825
Fax Number	:

Authorized Official
Title or Position	:	LEAD PSYCHOLOGIST
Name	:	DR. CANDACE M. STAFFORD
Credential	:	PSY.D.
Telephone Number	:	833-779-3825

Provider Enumeration Date	:	05/28/2025
Last Update Date	:	05/28/2025

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