Provider Demographics
NPI:1063764306
Name:FORD, VERONICA JOHNSON (MA)
Entity type:Individual
Prefix:MRS
First Name:VERONICA
Middle Name:JOHNSON
Last Name:FORD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 EWALD CIR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-3167
Mailing Address - Country:US
Mailing Address - Phone:313-590-3279
Mailing Address - Fax:313-590-3279
Practice Address - Street 1:3375 EWALD CIR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-3167
Practice Address - Country:US
Practice Address - Phone:313-590-3279
Practice Address - Fax:313-934-4658
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007505101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health