Provider Demographics
NPI:1952135394
Name:FORMAN, JOHN (PTA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:FORMAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 HYDE PARK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5834
Mailing Address - Country:US
Mailing Address - Phone:937-231-1089
Mailing Address - Fax:
Practice Address - Street 1:175 E ALEX BELL RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2701
Practice Address - Country:US
Practice Address - Phone:937-231-1089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA013847225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant