Basic Information
| Provider Information | |||||||||
| NPI: | 1003994005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | HOWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829015610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073526677 | ||||||||
| FaxNumber: | 3073526614 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829015610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073526677 | ||||||||
| FaxNumber: | 3073526614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | PMFT 217 | WY | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.