Provider Demographics
NPI:1538255278
Name:STANFORD, GARY (MS, CCC-A)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:STANFORD
Suffix:
Gender:M
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-6841
Mailing Address - Country:US
Mailing Address - Phone:605-338-6251
Mailing Address - Fax:605-333-0018
Practice Address - Street 1:301 W 14TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-6841
Practice Address - Country:US
Practice Address - Phone:605-338-6251
Practice Address - Fax:605-333-0018
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9150560Medicaid
SD0514040001Medicare ID - Type Unspecified