Provider Demographics
NPI:1760604748
Name:FORRET, MANDY JEAN (PTA)
Entity Type:Individual
Prefix:MS
First Name:MANDY
Middle Name:JEAN
Last Name:FORRET
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2905 GENE FIELD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-1913
Mailing Address - Country:US
Mailing Address - Phone:816-385-3744
Mailing Address - Fax:
Practice Address - Street 1:3302 N WOODBINE RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64505-9323
Practice Address - Country:US
Practice Address - Phone:724-392-4731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005026630225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant