Provider Demographics
NPI:1679779607
Name:FORD, EARNEST (LPC)
Entity type:Individual
Prefix:MR
First Name:EARNEST
Middle Name:
Last Name:FORD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2152 SOUTH VINEYARD
Mailing Address - Street 2:BLDG. 4 STE. 109-1
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5661
Mailing Address - Country:US
Mailing Address - Phone:480-507-3340
Mailing Address - Fax:480-507-3317
Practice Address - Street 1:115 W SAGEBRUSH ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-6916
Practice Address - Country:US
Practice Address - Phone:602-448-5970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-13204101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPC-13204OtherLICENSE