Provider Demographics
NPI:1417592502
Name:FORD, JUSTIN TYLER
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TYLER
Last Name:FORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6651 SILVER CREST RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:PA
Mailing Address - Zip Code:18014-8906
Mailing Address - Country:US
Mailing Address - Phone:484-526-7355
Mailing Address - Fax:
Practice Address - Street 1:6651 SILVER CREST RD STE 102
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:PA
Practice Address - Zip Code:18014-8906
Practice Address - Country:US
Practice Address - Phone:484-526-7355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT027108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist