Provider Demographics
NPI:1821768698
Name:FORD, MOIRA GRACE
Entity Type:Individual
Prefix:MISS
First Name:MOIRA
Middle Name:GRACE
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 1:1509 SOUTHCROSS DR W
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-6945
Mailing Address - Country:US
Mailing Address - Phone:952-491-9810
Mailing Address - Fax:
Practice Address - Street 1:223 CENTER ST
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3595
Practice Address - Country:US
Practice Address - Phone:507-474-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician