Healthcare Provider Details

I. General information

NPI: 1457417792
Provider Name (Legal Business Name): THOMAS W FORD PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MIZE STREET
LA FAYETTE GA
30728-1027
US

IV. Provider business mailing address

PO BOX 1027
LA FAYETTE GA
30728-1027
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-5584
  • Fax: 706-638-5585
Mailing address:
  • Phone: 706-638-5584
  • Fax: 706-638-5585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY002405
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: