Healthcare Provider Details

I. General information

NPI: 1548511843
Provider Name (Legal Business Name): MISS KEISHA N. FORDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 NORTHDALE BLVD STE 111W
TAMPA FL
33624-1853
US

IV. Provider business mailing address

555 AMORY ST
JAMAICA PLAIN MA
02130-2652
US

V. Phone/Fax

Practice location:
  • Phone: 813-418-7350
  • Fax:
Mailing address:
  • Phone: 617-383-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number10666
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT16802
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: