Provider Demographics
NPI:1114401213
Name:FORTHAUS, TESSA D (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:TESSA
Middle Name:D
Last Name:FORTHAUS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:THERESA
Other - Middle Name:D
Other - Last Name:FORTHAUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:243 KERRUISH PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-3001
Mailing Address - Country:US
Mailing Address - Phone:314-452-6397
Mailing Address - Fax:
Practice Address - Street 1:1393 BOWLES AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2355
Practice Address - Country:US
Practice Address - Phone:636-326-9606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005056225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist