MEDICARE: DR. LORA R. FORD PSYD PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY60004824	WA

General Provider Information

NPI Number	:	1912193038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LORA R. FORD PSYD PLLC

Provider Business Mailing Address
First Line	:	3240 W MERCER WAY
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-2540
Country	:	US
Telephone Number	:	206-632-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3035 ISLAND CREST WAY
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-2919
Country	:	US
Telephone Number	:	206-632-6000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2007
Last Update Date	:	02/17/2012

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