1639489412 NPI number — DR. GARY MILES FORREST LMFT, SAP

Table of content: DR. GARY MILES FORREST LMFT, SAP (NPI 1639489412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639489412 NPI number — DR. GARY MILES FORREST LMFT, SAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORREST
Provider First Name:
GARY
Provider Middle Name:
MILES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
LMFT, SAP
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:
1639489412
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 E OAKLAND PARK BLVD
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-308-7479
Provider Business Mailing Address Fax Number:
954-337-0530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 E OAKLAND PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-308-7479
Provider Business Practice Location Address Fax Number:
955-337-0530
Provider Enumeration Date:
10/14/2010

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: 101YA0400X , with the licence number:  20696 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: MT2443 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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