Provider Demographics
NPI:1316719792
Name:FORD, DEDRICK
Entity type:Individual
Prefix:MR
First Name:DEDRICK
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 1:8171 MIDTOWN BLVD APT 2214
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4483
Mailing Address - Country:US
Mailing Address - Phone:334-750-6548
Mailing Address - Fax:
Practice Address - Street 1:10300 N CENTRAL EXPY STE 280
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-8666
Practice Address - Country:US
Practice Address - Phone:214-430-4476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX93258101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health