Provider Demographics
NPI:1922125384
Name:FORD, CARLA ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:ANN
Last Name:FORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:CARLA
Other - Middle Name:ANN
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1758 W 100S
Mailing Address - Street 2:JAY COUNTY HOPSITAL BEHAVIORAL HEALTH
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371
Mailing Address - Country:US
Mailing Address - Phone:260-726-1865
Mailing Address - Fax:260-726-1901
Practice Address - Street 1:1758 W 100S
Practice Address - Street 2:JAY COUNTY HOPSITAL BEHAVIORAL HEALTH
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371
Practice Address - Country:US
Practice Address - Phone:260-726-1865
Practice Address - Fax:260-726-1901
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005252A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical