Basic Information
| Provider Information | |||||||||
| NPI: | 1376618033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FORD | ||||||||
| OtherFirstName: | DEBBIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 415 E MADISON ST | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465263452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745331234 | ||||||||
| FaxNumber: | 5745372652 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 E MADISON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466172322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745331234 | ||||||||
| FaxNumber: | 5745372652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 12/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 01075886B | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | 01075886A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 403931 | 05 | AZ | MEDICAID |