Provider Demographics
NPI:1548931462
Name:FORD, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5826 AMBROSE CIR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-4404
Mailing Address - Country:US
Mailing Address - Phone:770-733-5833
Mailing Address - Fax:
Practice Address - Street 1:5826 AMBROSE CIR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-4404
Practice Address - Country:US
Practice Address - Phone:214-433-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32078778894Medicaid