Provider Demographics
NPI:1548511843
Name:FORDE, KEISHA N
Entity type:Individual
Prefix:MISS
First Name:KEISHA
Middle Name:N
Last Name:FORDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 AMORY ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2652
Mailing Address - Country:US
Mailing Address - Phone:617-383-6522
Mailing Address - Fax:
Practice Address - Street 1:3903 NORTHDALE BLVD STE 111W
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1853
Practice Address - Country:US
Practice Address - Phone:813-418-7350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10666225XP0200X
FLOT16802225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT16802OtherOTLICENSE