Provider Demographics
NPI:1336416809
Name:FORD, CAROL (CCST)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:CCST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10490 SW EASTRIDGE ST
Mailing Address - Street 2:SUITE #130
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5030
Mailing Address - Country:US
Mailing Address - Phone:503-608-2372
Mailing Address - Fax:
Practice Address - Street 1:10490 SW EASTRIDGE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5030
Practice Address - Country:US
Practice Address - Phone:503-608-2372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACCST171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor