Provider Demographics
NPI:1073020350
Name:FORD, DESIREE DORIAN
Entity Type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:DORIAN
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 1:6950 EXETER CT APT 204
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-6480
Mailing Address - Country:US
Mailing Address - Phone:240-678-3299
Mailing Address - Fax:
Practice Address - Street 1:137 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-5400
Practice Address - Country:US
Practice Address - Phone:410-979-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-17-34575106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician