Provider Demographics
NPI:1275809725
Name:WILLOUGHBY FORDE, SHERYL
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:
Last Name:WILLOUGHBY FORDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 VANDERBILT AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-1106
Mailing Address - Country:US
Mailing Address - Phone:631-630-1998
Mailing Address - Fax:
Practice Address - Street 1:59 VANDERBILT AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-1106
Practice Address - Country:US
Practice Address - Phone:631-630-1998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist