Healthcare Provider Details

I. General information

NPI: 1558226233
Provider Name (Legal Business Name): CRYSTAL FORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 N 3RD ST
LEESVILLE LA
71446-4014
US

IV. Provider business mailing address

112 N 3RD ST
LEESVILLE LA
71446-4014
US

V. Phone/Fax

Practice location:
  • Phone: 318-795-3388
  • Fax: 318-795-3399
Mailing address:
  • Phone: 318-795-3388
  • Fax: 318-795-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberR-25337
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: