Healthcare Provider Details

I. General information

NPI: 1851203889
Provider Name (Legal Business Name): FORM PHYSICAL THERAPY & REHABILITATION PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7929 E 32ND ST STE 9
YUMA AZ
85365-8505
US

IV. Provider business mailing address

PO BOX 4219
YUMA AZ
85366-2415
US

V. Phone/Fax

Practice location:
  • Phone: 928-920-0386
  • Fax:
Mailing address:
  • Phone: 928-920-0386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KAYLA RENEE EVANS
Title or Position: OWNER
Credential:
Phone: 928-920-0386