Provider Demographics
NPI:1821862202
Name:FORNESS, KATHLEEN (DPT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:FORNESS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 NW 131ST AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-1351
Mailing Address - Country:US
Mailing Address - Phone:954-849-9640
Mailing Address - Fax:
Practice Address - Street 1:1551 PROFESSIONAL LN UNIT 145
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6968
Practice Address - Country:US
Practice Address - Phone:720-494-3290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
COPTL.0020533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist