Provider Demographics
NPI:1730461930
Name:FORD, TERA (PSY, D)
Entity Type:Individual
Prefix:DR
First Name:TERA
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:PSY, D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-0063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 S DE LACEY AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2048
Practice Address - Country:US
Practice Address - Phone:626-395-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25371103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical