Provider Demographics
NPI:1497385520
Name:FORT, ENRI (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ENRI
Middle Name:
Last Name:FORT
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:ENRI
Other - Middle Name:
Other - Last Name:YAMASHITA FORT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS,CCC-SLP
Mailing Address - Street 1:106 BLACK BEAR CIR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1202
Mailing Address - Country:US
Mailing Address - Phone:850-830-3314
Mailing Address - Fax:850-904-0355
Practice Address - Street 1:133 HOSPITAL DR NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5063
Practice Address - Country:US
Practice Address - Phone:850-830-3314
Practice Address - Fax:850-904-0355
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-16
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18378222Q00000X, 235Z00000X
235Z00000X
NC13863235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD12030298OtherASHA CCC
FL18378OtherFL DOH SLP