Provider Demographics
NPI:1376653311
Name:FORT, KEISHA (RPT)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:FORT
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 831
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-0831
Mailing Address - Country:US
Mailing Address - Phone:580-795-3301
Mailing Address - Fax:580-795-7307
Practice Address - Street 1:1212 FOUR SEASONS DR
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2430
Practice Address - Country:US
Practice Address - Phone:580-931-9218
Practice Address - Fax:580-924-1302
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3826225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist