Basic Information
| Provider Information | |||||||||
| NPI: | 1225483381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | NATHALIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9441 COMMON ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708091463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259233733 | ||||||||
| FaxNumber: | 2259233735 | ||||||||
| Practice Location | |||||||||
| Address1: | 9441 COMMON ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708091463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259233733 | ||||||||
| FaxNumber: | 2259233735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2016 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 600964601 | 05 | LA | MEDICAID |