Provider Demographics
NPI:1871745695
Name:STAFFORD, KIMBERLY NICOLE (LPC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:STAFFORD
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:770 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1187
Mailing Address - Country:US
Mailing Address - Phone:276-223-3200
Mailing Address - Fax:276-223-0617
Practice Address - Street 1:770 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1187
Practice Address - Country:US
Practice Address - Phone:276-223-3200
Practice Address - Fax:276-223-0617
Is Sole Proprietor?:No
Enumeration Date:2008-10-13
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004388101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA450666OtherMHN
VA004945298Medicaid
VA1871745695OtherANTHEM
VA450666OtherMHN - TRICARE