Provider Demographics
NPI:1376615641
Name:FORD, SUTAPA (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUTAPA
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6114 FAYETTEVILLE RD STE 109
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-6284
Mailing Address - Country:US
Mailing Address - Phone:919-942-4424
Mailing Address - Fax:919-942-4440
Practice Address - Street 1:6114 FAYETTEVILLE RD STE 109
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-6284
Practice Address - Country:US
Practice Address - Phone:919-942-4424
Practice Address - Fax:919-942-4440
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3006103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCSUTAPA FORDN/A1376Medicaid
NCSUTAPA FORD N/A 1376Medicaid