Provider Demographics
NPI:1184632820
Name:FORREST, LADESSA LYNN (OTR/L)
Entity Type:Individual
Prefix:
First Name:LADESSA
Middle Name:LYNN
Last Name:FORREST
Suffix:
Gender:F
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 1:10207 YOSEMITE DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67215-1580
Mailing Address - Country:US
Mailing Address - Phone:316-773-7975
Mailing Address - Fax:316-773-9766
Practice Address - Street 1:1401 CHERRY LN
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3152
Practice Address - Country:US
Practice Address - Phone:620-792-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-01870225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist