Basic Information
| Provider Information | |||||||||
| NPI: | 1245691070 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | HARRISON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17337 RESERVATION RD | ||||||||
| Address2: | |||||||||
| City: | LA CONNER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982578802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604661024 | ||||||||
| FaxNumber: | 3604667364 | ||||||||
| Practice Location | |||||||||
| Address1: | 8212 S MARCH POINT RD | ||||||||
| Address2: | |||||||||
| City: | ANACORTES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982218684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605882800 | ||||||||
| FaxNumber: | 3605882808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2016 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP60026494 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.