Provider Demographics
NPI:1487804985
Name:FORD, MELIZA MANGCO (LMFT, LPC)
Entity type:Individual
Prefix:MISS
First Name:MELIZA
Middle Name:MANGCO
Last Name:FORD
Suffix:
Gender:F
Credentials:LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 STEPHANIE DR
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-3542
Mailing Address - Country:US
Mailing Address - Phone:843-425-4109
Mailing Address - Fax:
Practice Address - Street 1:418 STEPHANIE DR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-3542
Practice Address - Country:US
Practice Address - Phone:843-425-4109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4849101YP2500X
SC4501106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
423976OtherMHN PROVIDER NUMBER (PIN)