Provider Demographics
NPI:1114429362
Name:FORT, LATRINA (DPT)
Entity Type:Individual
Prefix:MRS
First Name:LATRINA
Middle Name:
Last Name:FORT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LATRINA
Other - Middle Name:
Other - Last Name:BRAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:2801 PRESCOTT PL
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-2920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6500 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-2035
Practice Address - Country:US
Practice Address - Phone:405-767-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-04
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
OK4875225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty