Provider Demographics
NPI:1619039120
Name:FORD, MYRA J (MA PPC PAT)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:J
Last Name:FORD
Suffix:
Gender:F
Credentials:MA PPC PAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DEANNE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WY
Mailing Address - Zip Code:82701-2936
Mailing Address - Country:US
Mailing Address - Phone:307-746-4456
Mailing Address - Fax:307-746-4470
Practice Address - Street 1:420 DEANNE AVE
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WY
Practice Address - Zip Code:82701-2936
Practice Address - Country:US
Practice Address - Phone:307-746-4456
Practice Address - Fax:307-746-4470
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-221101YP2500X
WYPAT 016101YP2500X
WYLAT-299101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional