Provider Demographics
NPI:1528454105
Name:FORD, ALICIA (RD, LD, CDE)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:700 NE 87TH AVE STE 280
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1785
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-000980133V00000X, 133VN1004X
WADI60925857136A00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2044150Medicaid