MEDICARE: MRS. THERESA STANFORD LMHC

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	101YM0800X	Mental Health Counselor	MH3114	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215252374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA STANFORD LMHC

Provider Business Mailing Address
First Line	:	712 MUSKOGEE LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-7961
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4943 BEACH BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-4802
Country	:	US
Telephone Number	:	904-396-9144
Fax Number	:

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

Provider Enumeration Date	:	04/01/2010
Last Update Date	:	04/01/2010

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