Provider Demographics
NPI:1861753576
Name:FORD, KELLY NICOLE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:NICOLE
Last Name:FORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:RYDBOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:426 PHOENIX DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4537
Mailing Address - Country:US
Mailing Address - Phone:717-261-9833
Mailing Address - Fax:717-261-9832
Practice Address - Street 1:5157 BUSINESS 220
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:PA
Practice Address - Zip Code:15522
Practice Address - Country:US
Practice Address - Phone:814-623-2961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0173151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical