Provider Demographics
NPI:1174752711
Name:FORLAND, DIONNESHAE MONIQUE I (PTA)
Entity type:Individual
Prefix:
First Name:DIONNESHAE
Middle Name:MONIQUE
Last Name:FORLAND
Suffix:I
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9191 W FLORISSANT AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-1424
Mailing Address - Country:US
Mailing Address - Phone:314-524-3958
Mailing Address - Fax:314-524-3959
Practice Address - Street 1:9191 W FLORISSANT AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-1424
Practice Address - Country:US
Practice Address - Phone:314-524-3958
Practice Address - Fax:314-524-3959
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-03
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117525225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant