Healthcare Provider Details

I. General information

NPI: 1790040665
Provider Name (Legal Business Name): KARLETTE RAESHAUN FORD OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2314 S VAL VISTA DR STE 201
GILBERT AZ
85295-5594
US

IV. Provider business mailing address

8705 E KIVA AVE
MESA AZ
85209-5311
US

V. Phone/Fax

Practice location:
  • Phone: 623-263-3966
  • Fax:
Mailing address:
  • Phone: 708-271-7880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.002017
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTH-009793
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: