Provider Demographics
NPI:1043419609
Name:KUBLICK, FORREST (PSYD)
Entity Type:Individual
Prefix:DR
First Name:FORREST
Middle Name:
Last Name:KUBLICK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 NW KEARNEY ST
Mailing Address - Street 2:STE 14
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1463
Mailing Address - Country:US
Mailing Address - Phone:503-318-7736
Mailing Address - Fax:503-287-4355
Practice Address - Street 1:1942 NW KEARNEY ST
Practice Address - Street 2:STE 14
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1463
Practice Address - Country:US
Practice Address - Phone:503-318-7736
Practice Address - Fax:503-287-4355
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1660103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278037Medicaid
OR278037Medicaid