Provider Demographics
NPI:1497274633
Name:FORD, MAUREEN REGINA
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:REGINA
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 OAK ST
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-2329
Mailing Address - Country:US
Mailing Address - Phone:631-835-9741
Mailing Address - Fax:
Practice Address - Street 1:23 CANDEE AVE
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-3055
Practice Address - Country:US
Practice Address - Phone:855-552-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041013-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical