Provider Demographics
NPI:1194131946
Name:FORD, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:FORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 TATE AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1619
Mailing Address - Country:US
Mailing Address - Phone:937-414-5398
Mailing Address - Fax:
Practice Address - Street 1:228 N BARRON ST
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-1704
Practice Address - Country:US
Practice Address - Phone:937-456-7694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH120840101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)