Basic Information
| Provider Information | |||||||||
| NPI: | 1699905158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3536 PRAIRIE FOX LN | ||||||||
| Address2: | APARTMENT 4 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328124086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078160197 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2479 ALOMA AVE | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327922541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076576692 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2009 | ||||||||
| LastUpdateDate: | 07/19/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | IMH7592 | FL | N | Behavioral Health & Social Service Providers | Counselor | 106H00000X | IMT1297 | FL | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.