Provider Demographics
NPI:1891432043
Name:FORD, MACKENZIE RUTH (LDCD)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RUTH
Last Name:FORD
Suffix:
Gender:F
Credentials:LDCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10703 RANCH ROAD 12
Mailing Address - Street 2:
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-5239
Mailing Address - Country:US
Mailing Address - Phone:512-955-5510
Mailing Address - Fax:
Practice Address - Street 1:10703 RANCH ROAD 12
Practice Address - Street 2:
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676-5239
Practice Address - Country:US
Practice Address - Phone:512-955-5510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14425101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)