Provider Demographics
NPI:1164648721
Name:FORD, MICHAEL KEITH (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:FORD
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 4430
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021
Mailing Address - Country:US
Mailing Address - Phone:575-882-5101
Mailing Address - Fax:575-882-2858
Practice Address - Street 1:820 HWY 478
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021
Practice Address - Country:US
Practice Address - Phone:575-882-5101
Practice Address - Fax:575-882-2858
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-056591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical