Provider Demographics
NPI:1548615016
Name:FORD, ROBERT EARL (RADT-I R1225120316)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EARL
Last Name:FORD
Suffix:
Gender:M
Credentials:RADT-I R1225120316
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 ROCKLIN RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2860
Mailing Address - Country:US
Mailing Address - Phone:916-624-4428
Mailing Address - Fax:916-672-6289
Practice Address - Street 1:4200 ROCKLIN RD STE 1
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2860
Practice Address - Country:US
Practice Address - Phone:916-624-4428
Practice Address - Fax:916-672-6289
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1225120316101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)