Provider Demographics
NPI:1861433872
Name:FORD, BRUCE KEVIN (MSW)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:KEVIN
Last Name:FORD
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:G 4511 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507
Mailing Address - Country:US
Mailing Address - Phone:810-230-2640
Mailing Address - Fax:810-720-5434
Practice Address - Street 1:G 4511 MILLER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507
Practice Address - Country:US
Practice Address - Phone:810-230-2640
Practice Address - Fax:810-720-5434
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801071283104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WION58390Medicare ID - Type Unspecified