Provider Demographics
NPI:1376706135
Name:FORD, TERRANCE L (HIS)
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:L
Last Name:FORD
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 CORPORATE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:920-887-9655
Practice Address - Street 1:1004 1ST ST
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-2652
Practice Address - Country:US
Practice Address - Phone:715-341-4250
Practice Address - Fax:920-887-9655
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1294-060237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42840500Medicaid