Provider Demographics
NPI:1821425059
Name:FORSYTHE, LATOYA DOMINIQUE (DPT)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:DOMINIQUE
Last Name:FORSYTHE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 E GRADY STREET
Mailing Address - Street 2:APT F
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0908
Mailing Address - Country:US
Mailing Address - Phone:347-262-3518
Mailing Address - Fax:
Practice Address - Street 1:11 E GRADY STREET
Practice Address - Street 2:APT F
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0908
Practice Address - Country:US
Practice Address - Phone:347-262-3518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist