Provider Demographics
NPI:1912049347
Name:FORD, NICOLE (LICSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 GOULD ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-2903
Mailing Address - Country:US
Mailing Address - Phone:401-331-1350
Mailing Address - Fax:401-277-3366
Practice Address - Street 1:650 TEN ROD RD UNIT 13
Practice Address - Street 2:FAMILY SERVICE OF RHODE ISLAND
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-4237
Practice Address - Country:US
Practice Address - Phone:401-331-1350
Practice Address - Fax:401-277-3366
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW017271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
05025885813OtherPACIFICARE
12398751OtherMULTIPLAN
829691000OtherMAGELLAN
NF57510OtherMEDICAID
31134-0OtherBLUE CROSS-BLUE SHIELD
413185OtherBLUE CHIP
1021740OtherNHP GROUP NUMBER