Provider Demographics
NPI:1104833722
Name:FORREST, MARCIA GLEAVES (LCPC, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:GLEAVES
Last Name:FORREST
Suffix:
Gender:F
Credentials:LCPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 N MAIN ST.
Mailing Address - Street 2:SUITE C
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137
Mailing Address - Country:US
Mailing Address - Phone:630-627-2588
Mailing Address - Fax:630-980-9242
Practice Address - Street 1:516 N MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5175
Practice Address - Country:US
Practice Address - Phone:630-627-2588
Practice Address - Fax:630-980-9242
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0002232107OtherBCBS PROVIDER #