Provider Demographics
NPI:1144756222
Name:FORDSON, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:FORDSON
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 1:3713 COVENANT RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-4217
Mailing Address - Country:US
Mailing Address - Phone:888-753-0009
Mailing Address - Fax:
Practice Address - Street 1:3739 OAKLEAF RD APT A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-5202
Practice Address - Country:US
Practice Address - Phone:803-638-2786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9888225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist