Provider Demographics
NPI:1255009882
Name:FORD, TYRONE D (LCSW)
Entity type:Individual
Prefix:MR
First Name:TYRONE
Middle Name:D
Last Name:FORD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10850 LINCOLN TRL # 20-1861
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-0339
Mailing Address - Country:US
Mailing Address - Phone:314-718-4503
Mailing Address - Fax:618-416-2708
Practice Address - Street 1:10850 LINCOLN TRL # 20-1861
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-0339
Practice Address - Country:US
Practice Address - Phone:314-718-4503
Practice Address - Fax:618-416-2708
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0181801041C0700X
MO20160023221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty