Provider Demographics
NPI:1639943533
Name:FORD, MICHEAL
Entity Type:Individual
Prefix:
First Name:MICHEAL
Middle Name:
Last Name:FORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 DRIFTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:BAY POINT
Mailing Address - State:CA
Mailing Address - Zip Code:94565-1378
Mailing Address - Country:US
Mailing Address - Phone:510-517-0244
Mailing Address - Fax:
Practice Address - Street 1:3155 KEARNEY ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2268
Practice Address - Country:US
Practice Address - Phone:800-846-1652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1533341023101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)