Provider Demographics
NPI:1487893350
Name:FORD, FANISHA R (LOTR)
Entity type:Individual
Prefix:MS
First Name:FANISHA
Middle Name:R
Last Name:FORD
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 OVERTON AVE
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-2742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:436 OVERTON AVE
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-2742
Practice Address - Country:US
Practice Address - Phone:318-623-7331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-16
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z12052225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist