Healthcare Provider Details

I. General information

NPI: 1679779607
Provider Name (Legal Business Name): EARNEST FORD LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 09/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W SAGEBRUSH ST
GILBERT AZ
85233-6916
US

IV. Provider business mailing address

2152 SOUTH VINEYARD BLDG. 4 STE. 109-1
MESA AZ
85201-5661
US

V. Phone/Fax

Practice location:
  • Phone: 602-448-5970
  • Fax:
Mailing address:
  • Phone: 480-507-3340
  • Fax: 480-507-3317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-13204
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: