Basic Information
| Provider Information | |||||||||
| NPI: | 1740780634 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANFORD | ||||||||
| FirstName: | ALECIA | ||||||||
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| Credential: | BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 N WALTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727124576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794641060 | ||||||||
| FaxNumber: | 4792716307 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 LENTZ RD | ||||||||
| Address2: | |||||||||
| City: | MORRILTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721103740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013541170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2018 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 222Q00000X | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.