Provider Demographics
NPI:1003350521
Name:FORGING FORTITUDE
Entity Type:Organization
Organization Name:FORGING FORTITUDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CURTIS
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:775-530-0188
Mailing Address - Street 1:427 S MAIN ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-3955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:427 S MAIN ST
Practice Address - Street 2:SUITE 305
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-3955
Practice Address - Country:US
Practice Address - Phone:775-530-0188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7448466-3902251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health