Provider Demographics
NPI:1013361898
Name:FORD, ROSE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11606 SOUTHFORK AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-5235
Mailing Address - Country:US
Mailing Address - Phone:225-293-2913
Mailing Address - Fax:
Practice Address - Street 1:11606 SOUTHFORK AVE STE 101
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-5235
Practice Address - Country:US
Practice Address - Phone:225-293-2913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC6493101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor