Provider Demographics
NPI:1215560479
Name:FORD, MARY ELIZABETH
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 GIBSON RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-3429
Mailing Address - Country:US
Mailing Address - Phone:803-814-5559
Mailing Address - Fax:803-878-7600
Practice Address - Street 1:130 GIBSON RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-3429
Practice Address - Country:US
Practice Address - Phone:803-814-5559
Practice Address - Fax:803-878-7600
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6921101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional