1679968861 NPI number — FOREST LICENSED CLINICAL SOCIAL WORK P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679968861 NPI number — FOREST LICENSED CLINICAL SOCIAL WORK P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOREST LICENSED CLINICAL SOCIAL WORK P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679968861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2691 STATE ROUTE 9 # 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MALTA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12020-4319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-400-1448
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2691 STATE ROUTE 9 # 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALTA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12020-4319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-400-1448
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CLAIRMONT
Authorized Official First Name:
JENNESS
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
518-400-1448

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  R071476-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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