Healthcare Provider Details

I. General information

NPI: 1255645495
Provider Name (Legal Business Name): LARRY FORD JR. DBH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 SW 44TH ST STE 500
OKLAHOMA CITY OK
73109-3615
US

IV. Provider business mailing address

1016 SW 44TH ST STE 500
OKLAHOMA CITY OK
73109-3615
US

V. Phone/Fax

Practice location:
  • Phone: 405-605-4249
  • Fax: 405-605-0255
Mailing address:
  • Phone: 405-605-4249
  • Fax: 405-605-0255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License Number1836
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: