Healthcare Provider Details

I. General information

NPI: 1073677357
Provider Name (Legal Business Name): ANTHONY JASON LAFORME OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 IRELAND AVE
FORT KNOX KY
40121-5111
US

IV. Provider business mailing address

255 PAIGE MEREDITH PKWY
BRANDENBURG KY
40108-5464
US

V. Phone/Fax

Practice location:
  • Phone: 502-624-9905
  • Fax: 502-624-0211
Mailing address:
  • Phone: 248-467-9046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number5201006031
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT4030
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number5201006031
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: