Healthcare Provider Details

I. General information

NPI: 1093624538
Provider Name (Legal Business Name): NATHANIEL SHAWON FORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7823 N DALE MABRY HWY STE 106
TAMPA FL
33614-3273
US

IV. Provider business mailing address

7823 N DALE MABRY HWY STE 106
TAMPA FL
33614-3273
US

V. Phone/Fax

Practice location:
  • Phone: 904-234-1063
  • Fax:
Mailing address:
  • Phone: 904-234-1063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH29751
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: