Provider Demographics
NPI:1417597576
Name:FORD, DEJAH
Entity type:Individual
Prefix:
First Name:DEJAH
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 1:12 BALABAN RD APT 507
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-1793
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 S MAIN ST STE 300A
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3764
Practice Address - Country:US
Practice Address - Phone:860-712-6791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT142041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical