Provider Demographics
NPI:1578876041
Name:FORD, JOSEPH R (PT, DPT, FAAOMPT)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
Last Name:FORD
Suffix:
Gender:M
Credentials:PT, DPT, FAAOMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 52ND ST
Mailing Address - Street 2:STE 240
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-3423
Mailing Address - Country:US
Mailing Address - Phone:262-925-5004
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:STE 103
Practice Address - City:TWIN LAKES
Practice Address - State:WI
Practice Address - Zip Code:53181-4200
Practice Address - Country:US
Practice Address - Phone:262-925-5240
Practice Address - Fax:262-925-5241
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11490-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12507054OtherCAQH
12507054OtherCAQH