Provider Demographics
NPI:1952302358
Name:FORD, GARY E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:FORD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 TORREY PNES
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-8614
Mailing Address - Country:US
Mailing Address - Phone:937-408-7711
Mailing Address - Fax:
Practice Address - Street 1:2510 5TH ST
Practice Address - Street 2:
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-7951
Practice Address - Country:US
Practice Address - Phone:937-938-2704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4588103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist