1063912681 NPI number — SHIRLEY MOORE FORD MS, LPC, NCC, MAC

Table of content: SHIRLEY MOORE FORD MS, LPC, NCC, MAC (NPI 1063912681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063912681 NPI number — SHIRLEY MOORE FORD MS, LPC, NCC, MAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORD
Provider First Name:
SHIRLEY
Provider Middle Name:
MOORE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC, NCC, MAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063912681
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 FLEETWOOD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRATTVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36067-4028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-275-8251
Provider Business Mailing Address Fax Number:
334-382-6353

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
185 INDUSTRIAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36037-2421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-382-2108
Provider Business Practice Location Address Fax Number:
334-382-6353
Provider Enumeration Date:
02/20/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  3266 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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