Provider Demographics
NPI:1316075294
Name:FORD, PERCY JR (MC,LPC-MHSP,NCC)
Entity type:Individual
Prefix:MR
First Name:PERCY
Middle Name:
Last Name:FORD
Suffix:JR
Gender:M
Credentials:MC,LPC-MHSP,NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5165 BROOKSTONE CT
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-5687
Mailing Address - Country:US
Mailing Address - Phone:615-692-4935
Mailing Address - Fax:855-261-6356
Practice Address - Street 1:310 UPTOWN SQ
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-0574
Practice Address - Country:US
Practice Address - Phone:615-692-4935
Practice Address - Fax:855-261-6356
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TN2643101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3376955Medicare ID - Type UnspecifiedGROUP NUMBER