Provider Demographics
NPI:1639703309
Name:FORD, CLARISSA D
Entity type:Individual
Prefix:MRS
First Name:CLARISSA
Middle Name:D
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:DENYSE
Other - Last Name:FORD-EDWUNWOKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 BAILEY RD APT 114B
Mailing Address - Street 2:
Mailing Address - City:BAY POINT
Mailing Address - State:CA
Mailing Address - Zip Code:94565-6622
Mailing Address - Country:US
Mailing Address - Phone:925-238-5061
Mailing Address - Fax:
Practice Address - Street 1:110 BAILEY RD APT 114B
Practice Address - Street 2:
Practice Address - City:BAY POINT
Practice Address - State:CA
Practice Address - Zip Code:94565-6622
Practice Address - Country:US
Practice Address - Phone:925-238-5061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)