Provider Demographics
NPI:1538255534
Name:STANFORTH, GARY D (LISW)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:D
Last Name:STANFORTH
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9733 DEBOLD KOEBEL RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PLAIN
Mailing Address - State:OH
Mailing Address - Zip Code:45162-9353
Mailing Address - Country:US
Mailing Address - Phone:513-535-7668
Mailing Address - Fax:
Practice Address - Street 1:8401 CLAUDE THOMAS RD
Practice Address - Street 2:SUITE 21F
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-1497
Practice Address - Country:US
Practice Address - Phone:513-535-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH991476101YA0400X
OHI-0007783101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)