Provider Demographics
NPI:1730273335
Name:FORDHAM, THERESA FLANAGAN (LPC LSW)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:FLANAGAN
Last Name:FORDHAM
Suffix:
Gender:F
Credentials:LPC LSW
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:FLANAGAN
Other - Last Name:STALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC LSW MAC
Mailing Address - Street 1:PO BOX 7884
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506
Mailing Address - Country:US
Mailing Address - Phone:228-596-9903
Mailing Address - Fax:228-396-5001
Practice Address - Street 1:1636 POPPS FERRY RD STE 116
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532
Practice Address - Country:US
Practice Address - Phone:228-596-9903
Practice Address - Fax:228-396-5001
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0934101YP2500X
MSW4171104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSA931421OtherVALUE OPTIONS
MS472900000OtherMAGELLAN HEALTH
MS822222189Medicare ID - Type Unspecified
MS800000189Medicare UPIN