Provider Demographics
NPI:1700968138
Name:FORDE, KATHLEEN M (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:FORDE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4870 TWIN LAKES TRL
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30360-1727
Mailing Address - Country:US
Mailing Address - Phone:678-662-0565
Mailing Address - Fax:
Practice Address - Street 1:575 PROFESSIONAL DR STE 160
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3347
Practice Address - Country:US
Practice Address - Phone:770-995-9746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist