Basic Information
Provider Information | |||||||||
NPI: | 1912049347 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FORD | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 73 GOULD ST | ||||||||
Address2: |   | ||||||||
City: | WAKEFIELD | ||||||||
State: | RI | ||||||||
PostalCode: | 028792903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4013311350 | ||||||||
FaxNumber: | 4012773366 | ||||||||
Practice Location | |||||||||
Address1: | 650 TEN ROD RD UNIT 13 | ||||||||
Address2: | FAMILY SERVICE OF RHODE ISLAND | ||||||||
City: | NORTH KINGSTOWN | ||||||||
State: | RI | ||||||||
PostalCode: | 028524237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4013311350 | ||||||||
FaxNumber: | 4012773366 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/13/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
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 | 1041C0700X | ISW01727 | RI | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 05025885813 | 01 |   | PACIFICARE | OTHER | 12398751 | 01 |   | MULTIPLAN | OTHER | 829691000 | 01 |   | MAGELLAN | OTHER | NF57510 | 01 |   | MEDICAID | OTHER | 31134-0 | 01 |   | BLUE CROSS-BLUE SHIELD | OTHER | 413185 | 01 |   | BLUE CHIP | OTHER | 1021740 | 01 |   | NHP GROUP NUMBER | OTHER |