Provider Demographics
NPI:1700330651
Name:FORD, RYAN T
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:T
Last Name:FORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 NORWOOD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-1601
Mailing Address - Country:US
Mailing Address - Phone:252-493-6525
Mailing Address - Fax:
Practice Address - Street 1:2307 NORWOOD AVE STE A
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-1601
Practice Address - Country:US
Practice Address - Phone:252-493-6525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10947101YM0800X
NE565101YM0800X
NC5476103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health