Provider Demographics
NPI:1114236528
Name:FORLENZA, PETER MICHAEL
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:MICHAEL
Last Name:FORLENZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 SPRING ST
Mailing Address - Street 2:PO BOX 247
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-8057
Mailing Address - Country:US
Mailing Address - Phone:360-298-1630
Mailing Address - Fax:360-378-5669
Practice Address - Street 1:520 SPRING ST
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-8057
Practice Address - Country:US
Practice Address - Phone:360-298-1630
Practice Address - Fax:360-378-5669
Is Sole Proprietor?:No
Enumeration Date:2010-10-03
Last Update Date:2010-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACDPT.CO.60187485171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator