Provider Demographics
NPI:1275738700
Name:FORD-WOLFGRAM, TERRI R (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TERRI
Middle Name:R
Last Name:FORD-WOLFGRAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:R
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:110 N 16TH ST STE 16
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-3671
Mailing Address - Country:US
Mailing Address - Phone:402-644-7314
Mailing Address - Fax:402-644-7315
Practice Address - Street 1:110 N 16TH ST STE 16
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-3671
Practice Address - Country:US
Practice Address - Phone:402-644-7314
Practice Address - Fax:402-644-7315
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13411041C0700X
NE3624101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025531200Medicaid