Provider Demographics
NPI:1891704219
Name:FORD, EVA (LISW)
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W BURLINGTON
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-3242
Mailing Address - Country:US
Mailing Address - Phone:641-472-1684
Mailing Address - Fax:641-472-4609
Practice Address - Street 1:605 EAST WINFIELD AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:IA
Practice Address - Zip Code:52641-2047
Practice Address - Country:US
Practice Address - Phone:319-385-8051
Practice Address - Fax:319-385-7010
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01917104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA247048OtherMIDLANDS