Provider Demographics
NPI:1710674486
Name:FORD, SAM R (CDCA 11)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:R
Last Name:FORD
Suffix:
Gender:M
Credentials:CDCA 11
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 W CENTRAL AVE APT 2B
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3715
Mailing Address - Country:US
Mailing Address - Phone:419-360-8251
Mailing Address - Fax:
Practice Address - Street 1:500 MADISON AVE STE 340
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1277
Practice Address - Country:US
Practice Address - Phone:419-360-8251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA162201101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)