Provider Demographics
NPI:1245840099
Name:STAFFORD, GENEVIEVE (LCMHCA)
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 N ELM ST APT 3N
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2864
Mailing Address - Country:US
Mailing Address - Phone:845-522-2647
Mailing Address - Fax:
Practice Address - Street 1:1180 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-9856
Practice Address - Country:US
Practice Address - Phone:336-283-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15750101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health