1063603074 NPI number — MR. TERRY ALAN FORREST LPC, LMFT

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 1063603074 NPI number — MR. TERRY ALAN FORREST LPC, LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORREST
Provider First Name:
TERRY
Provider Middle Name:
ALAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPC, LMFT
Provider Gender Code:
M

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:
1063603074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3007
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-535-1174
Provider Business Mailing Address Fax Number:
503-535-1191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
419 CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-2211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-506-1887
Provider Business Practice Location Address Fax Number:
503-656-0649
Provider Enumeration Date:
08/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  T0274 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: C0410 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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