Provider Demographics
NPI:1407015787
Name:M FORD MCBRIDE, PHD, PC
Entity Type:Organization
Organization Name:M FORD MCBRIDE, PHD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:MCBRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-357-7757
Mailing Address - Street 1:1055 N 300 W
Mailing Address - Street 2:414
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3344
Mailing Address - Country:US
Mailing Address - Phone:801-357-7757
Mailing Address - Fax:801-357-8100
Practice Address - Street 1:1055 N 300 W
Practice Address - Street 2:414
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3344
Practice Address - Country:US
Practice Address - Phone:801-357-7757
Practice Address - Fax:801-357-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT109867-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000004109Medicare PIN