Provider Demographics
NPI:1407166739
Name:FORD, ERIN WALLEY (LMHP, CMSW, LICSW)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:WALLEY
Last Name:FORD
Suffix:
Gender:F
Credentials:LMHP, CMSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1101 MADISON ST STE 700
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3599
Practice Address - Country:US
Practice Address - Phone:206-215-6300
Practice Address - Fax:206-215-6301
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60840883104100000X, 1041C0700X
KS38991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1407166739Medicaid