Provider Demographics
NPI:1548735475
Name:FORD, MADELAINE (LAC)
Entity Type:Individual
Prefix:
First Name:MADELAINE
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 S LINDSAY RD STE 124
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-1508
Mailing Address - Country:US
Mailing Address - Phone:480-567-0737
Mailing Address - Fax:
Practice Address - Street 1:4100 S LINDSAY RD STE 124
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-1508
Practice Address - Country:US
Practice Address - Phone:480-567-0737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AZ101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health