Provider Demographics
NPI:1043984297
Name:FORD, DARRELL DEMETRIUS
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:DEMETRIUS
Last Name:FORD
Suffix:
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 1:2239 MEMORY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-5828
Mailing Address - Country:US
Mailing Address - Phone:910-797-3159
Mailing Address - Fax:
Practice Address - Street 1:312 W MILLBROOK RD STE 129
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4398
Practice Address - Country:US
Practice Address - Phone:919-877-6101
Practice Address - Fax:919-876-4953
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16820101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health