Provider Demographics
NPI:1750056560
Name:FORD, DESIREE ALECE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:ALECE
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 1:5725 NE PRESCOTT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2275
Mailing Address - Country:US
Mailing Address - Phone:503-402-8101
Mailing Address - Fax:
Practice Address - Street 1:5725 NE PRESCOTT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-2275
Practice Address - Country:US
Practice Address - Phone:503-402-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226398Medicaid