Provider Demographics
NPI:1619192663
Name:FORD, GREGORY LEE (MFT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:LEE
Last Name:FORD
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11159 BRITTANY LN
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-3530
Mailing Address - Country:US
Mailing Address - Phone:925-875-9091
Mailing Address - Fax:
Practice Address - Street 1:1811 SANTA RITA RD
Practice Address - Street 2:SUITE 216
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-4746
Practice Address - Country:US
Practice Address - Phone:925-462-9776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37126106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist