Provider Demographics
NPI:1790040665
Name:FORD, KARLETTE RAESHAUN (OT)
Entity type:Individual
Prefix:MISS
First Name:KARLETTE
Middle Name:RAESHAUN
Last Name:FORD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8705 E KIVA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-5311
Mailing Address - Country:US
Mailing Address - Phone:708-271-7880
Mailing Address - Fax:
Practice Address - Street 1:2314 S VAL VISTA DR STE 201
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-5594
Practice Address - Country:US
Practice Address - Phone:623-263-3966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-009793225X00000X
IL057.002017224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant