Provider Demographics
NPI:1376699801
Name:FORD, DEMETRIUS EDWIN (LP, PHD)
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:EDWIN
Last Name:FORD
Suffix:
Gender:M
Credentials:LP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 LIVERNOIS RD STE 500
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1219
Mailing Address - Country:US
Mailing Address - Phone:248-680-8203
Mailing Address - Fax:248-680-8030
Practice Address - Street 1:22151 MOROSS
Practice Address - Street 2:PROFESSIONAL BUILDING 1 SUITE 334
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2196
Practice Address - Country:US
Practice Address - Phone:313-343-7230
Practice Address - Fax:313-343-7449
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009054103T00000X
MI6301018364103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist