Healthcare Provider Details

I. General information

NPI: 1508603796
Provider Name (Legal Business Name): ANTOINETTE FORD LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2024
Last Update Date: 07/13/2024
Certification Date: 07/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 N 6TH AVE
PHOENIX AZ
85003-1318
US

IV. Provider business mailing address

1117 E CAROB DR
CHANDLER AZ
85286-2521
US

V. Phone/Fax

Practice location:
  • Phone: 602-462-1115
  • Fax:
Mailing address:
  • Phone: 480-205-4202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC23175
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: