Provider Demographics
NPI:1013346030
Name:FORREST, KATHLEEN (PTA)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:FORREST
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:DE
Mailing Address - Zip Code:19804-3020
Mailing Address - Country:US
Mailing Address - Phone:302-478-5240
Mailing Address - Fax:302-478-2594
Practice Address - Street 1:3411 SILVERSIDE RD
Practice Address - Street 2:SPRINGER BLDG SUITE 105
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4812
Practice Address - Country:US
Practice Address - Phone:302-478-5240
Practice Address - Fax:302-478-2594
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ20000173174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEG00716Medicaid
DEG00716Medicaid