Provider Demographics
NPI:1356888754
Name:FORD, KRISTY M (PHD, LMHC)
Entity type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:M
Last Name:FORD
Suffix:
Gender:F
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5137 MENAWA TRL
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-0148
Mailing Address - Country:US
Mailing Address - Phone:850-573-2080
Mailing Address - Fax:
Practice Address - Street 1:5137 MENAWA TRL
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-0148
Practice Address - Country:US
Practice Address - Phone:850-573-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 12046101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health