Provider Demographics
NPI:1154860302
Name:FORD, KIESHA (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KIESHA
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 FORT HENRY RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-6622
Mailing Address - Country:US
Mailing Address - Phone:618-795-0569
Mailing Address - Fax:
Practice Address - Street 1:6 EMERALD TER STE 4
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2312
Practice Address - Country:US
Practice Address - Phone:618-516-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178000601101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional