Healthcare Provider Details

I. General information

NPI: 1013346030
Provider Name (Legal Business Name): KATHLEEN FORREST PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 SILVERSIDE RD SPRINGER BLDG SUITE 105
WILMINGTON DE
19810-4812
US

IV. Provider business mailing address

413 CLEVELAND AVE
NEWPORT DE
19804-3020
US

V. Phone/Fax

Practice location:
  • Phone: 302-478-5240
  • Fax: 302-478-2594
Mailing address:
  • Phone: 302-478-5240
  • Fax: 302-478-2594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberJ20000173
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: