MEDICARE: DIONNESHAE MONIQUE FORLAND I PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	117525	MO

General Provider Information

NPI Number	:	1174752711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIONNESHAE MONIQUE FORLAND I PTA

Provider Business Mailing Address
First Line	:	9191 W FLORISSANT AVE
Second Line	:	SUITE 200
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-1424
Country	:	US
Telephone Number	:	314-524-3958
Fax Number	:	314-524-3959

Provider Business Practice Location Address
First Line	:	9191 W FLORISSANT AVE
Second Line	:	SUITE 200
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-1424
Country	:	US
Telephone Number	:	314-524-3958
Fax Number	:	314-524-3959

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2009
Last Update Date	:	06/18/2013

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