Provider Demographics
NPI:1003325119
Name:FORD, DAVID LEE JR
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:FORD
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 TUSCARORA RD
Mailing Address - Street 2:
Mailing Address - City:CHITTENANGO
Mailing Address - State:NY
Mailing Address - Zip Code:13037-9731
Mailing Address - Country:US
Mailing Address - Phone:518-368-5733
Mailing Address - Fax:
Practice Address - Street 1:375 W ONONDAGA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-1888
Practice Address - Country:US
Practice Address - Phone:315-478-2030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty