Provider Demographics
NPI:1760890008
Name:FORD, CRYSTAL (MA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 MITCHELLVILLE RD
Mailing Address - Street 2:201
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1385
Mailing Address - Country:US
Mailing Address - Phone:703-859-1709
Mailing Address - Fax:
Practice Address - Street 1:2905 MITCHELLVILLE RD
Practice Address - Street 2:201
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1385
Practice Address - Country:US
Practice Address - Phone:703-859-1709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor