Basic Information
Provider Information | |||||||||
NPI: | 1689872780 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FORD | ||||||||
FirstName: | MONICA | ||||||||
MiddleName: | JOYCE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FORD | ||||||||
OtherFirstName: | MONICA | ||||||||
OtherMiddleName: | JOYCE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 11456 NE KNOTT ST | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972201706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037366500 | ||||||||
FaxNumber: | 5032569601 | ||||||||
Practice Location | |||||||||
Address1: | 1500 NE IRVING ST | ||||||||
Address2: | 250 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972322243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032334356 | ||||||||
FaxNumber: | 5032334359 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2007 | ||||||||
LastUpdateDate: | 08/15/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   |   | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.