Provider Demographics
NPI:1073677357
Name:LAFORME, ANTHONY JASON (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:JASON
Last Name:LAFORME
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4274 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-2168
Mailing Address - Country:US
Mailing Address - Phone:248-467-9046
Mailing Address - Fax:
Practice Address - Street 1:289 IRELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-624-9905
Practice Address - Fax:502-624-0211
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006031174400000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No174400000XOther Service ProvidersSpecialist