Provider Demographics
NPI:1790884310
Name:FORD, COLLEEN A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:A
Last Name:FORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MANHASSET TRL
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-2281
Mailing Address - Country:US
Mailing Address - Phone:631-886-1294
Mailing Address - Fax:
Practice Address - Street 1:1841 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4625
Practice Address - Country:US
Practice Address - Phone:631-853-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0741681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW02761Medicare ID - Type Unspecified