MEDICARE: FORD CREATIVE COUNSELING SERVICES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R039633-1	NY

General Provider Information

NPI Number	:	1275078917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORD CREATIVE COUNSELING SERVICES, INC

Provider Business Mailing Address
First Line	:	64 ALLEN ST
Second Line	:
City	:	HEMPSTEAD
State	:	NY
Zip	:	11550-7318
Country	:	US
Telephone Number	:	718-978-6075
Fax Number	:

Provider Business Practice Location Address
First Line	:	11907 229TH ST
Second Line	:
City	:	CAMBRIA HEIGHTS
State	:	NY
Zip	:	11411-2205
Country	:	US
Telephone Number	:	718-978-6075
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	MS. LINDA R FORD
Credential	:	LCSW
Telephone Number	:	718-978-6075

Provider Enumeration Date	:	01/05/2017
Last Update Date	:	01/05/2017

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