=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760604748
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANDY JEAN FORRET PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 01/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3302 N WOODBINE RD
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64505-9323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-392-4731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2905 GENE FIELD RD
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64506-1913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-385-3744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2005026630
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------