Provider Demographics
NPI:1235828518
Name:FORD, MIRRIAM RUGURUE
Entity Type:Individual
Prefix:
First Name:MIRRIAM
Middle Name:RUGURUE
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 1:300 SKY DR
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-6360
Mailing Address - Country:US
Mailing Address - Phone:219-614-9456
Mailing Address - Fax:
Practice Address - Street 1:300 SKY DR
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-6360
Practice Address - Country:US
Practice Address - Phone:219-614-9456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810008082103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical