Provider Demographics
NPI:1629540281
Name:FORD, KATHLEEN M (MA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:FORD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 FLAGLER AVE
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-5368
Mailing Address - Country:US
Mailing Address - Phone:239-770-8998
Mailing Address - Fax:
Practice Address - Street 1:822 DEL PRADO BLVD S STE 120
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2687
Practice Address - Country:US
Practice Address - Phone:239-770-8998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26068225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty