Provider Demographics
NPI:1659609618
Name:FORST, REBECCA DECLERK (MPT)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:DECLERK
Last Name:FORST
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 PENNY CT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7733 FORSYTH BLVD STE 2300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-1806
Practice Address - Country:US
Practice Address - Phone:800-677-1238
Practice Address - Fax:314-863-0769
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009023136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist