Provider Demographics
NPI:1093262933
Name:FORD, KRISTINE GRACE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:GRACE
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 1:2203 OLD HWY 99 S
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-9009
Mailing Address - Country:US
Mailing Address - Phone:360-542-8810
Mailing Address - Fax:360-542-8811
Practice Address - Street 1:2203 OLD HWY 99 S
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-542-8810
Practice Address - Fax:360-542-8811
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH661146191444101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health