1417168329 NPI number — MR. RICHARD A. STANDIFORD LCSW

Table of content: MR. RICHARD A. STANDIFORD LCSW (NPI 1417168329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417168329 NPI number — MR. RICHARD A. STANDIFORD LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STANDIFORD
Provider First Name:
RICHARD
Provider Middle Name:
A.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417168329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 1ST STREET SE
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
BANDON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97411-9353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-347-2529
Provider Business Mailing Address Fax Number:
541-347-9196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 1ST STREET SE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
BANDON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97411-9353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-347-2529
Provider Business Practice Location Address Fax Number:
541-347-9196
Provider Enumeration Date:
05/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: L5400 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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