Provider Demographics
NPI:1962523688
Name:FORTE, KATHLEEN ANN (PTA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:FORTE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 AZURE LN
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-2860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:524 N WEST BLVD
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-2845
Practice Address - Country:US
Practice Address - Phone:856-405-4233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00190600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant