Provider Demographics
NPI:1053493494
Name:STAFFORD, DARLA J (LICSW)
Entity type:Individual
Prefix:
First Name:DARLA
Middle Name:J
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:701-323-6000
Mailing Address - Fax:701-323-5709
Practice Address - Street 1:1800 E INTERSTATE AVE STE B
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1566
Practice Address - Country:US
Practice Address - Phone:701-323-6543
Practice Address - Fax:701-323-5492
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19107Medicaid
ND19107Medicaid
ND19082Medicare ID - Type Unspecified