Provider Demographics
NPI:1720378532
Name:FORD, MISSOURI
Entity Type:Individual
Prefix:
First Name:MISSOURI
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 W MISSOURI AVE
Mailing Address - Street 2:#408
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2605
Mailing Address - Country:US
Mailing Address - Phone:602-643-6577
Mailing Address - Fax:
Practice Address - Street 1:1735 W MISSOURI AVE
Practice Address - Street 2:#408
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2605
Practice Address - Country:US
Practice Address - Phone:602-643-6577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2477902385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child