Provider Demographics
NPI:1366979486
Name:FORD, SHERYL R (LCSW, ACH)
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:R
Last Name:FORD
Suffix:
Gender:F
Credentials:LCSW, ACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 E CHOLLA HILLS ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5679
Mailing Address - Country:US
Mailing Address - Phone:208-350-1576
Mailing Address - Fax:
Practice Address - Street 1:3225 W BAVARIA ST STE 123
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5547
Practice Address - Country:US
Practice Address - Phone:208-350-1576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64091041C0700X
IDLCSW-312141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCSW-31214OtherSTATE LICENSE
OR6409OtherSTATE LICENSE