Provider Demographics
NPI:1447395447
Name:FORD, JUILANN MARIE (MA, CCCSLP)
Entity Type:Individual
Prefix:
First Name:JUILANN
Middle Name:MARIE
Last Name:FORD
Suffix:
Gender:F
Credentials:MA, CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N MAIN ST
Mailing Address - Street 2:SUITE 820
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1625
Mailing Address - Country:US
Mailing Address - Phone:574-234-7244
Mailing Address - Fax:574-234-9663
Practice Address - Street 1:108 N MAIN ST
Practice Address - Street 2:SUITE 820
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1625
Practice Address - Country:US
Practice Address - Phone:574-234-7244
Practice Address - Fax:574-234-9663
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22001708A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000195716OtherBLUE CROSS BLUE SHIELD