Provider Demographics
NPI:1376699801
Name:FORD, DEMETRIUS EDWIN (LP, PHD)
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:EDWIN
Last Name:FORD
Suffix:
Gender:M
Credentials:LP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 KERCHEVAL AVE STE 317
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3698
Mailing Address - Country:US
Mailing Address - Phone:313-806-9535
Mailing Address - Fax:
Practice Address - Street 1:21 KERCHEVAL AVE STE 371
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3698
Practice Address - Country:US
Practice Address - Phone:313-806-9535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009054103T00000X
MI6301018364103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist