Provider Demographics
NPI:1124376298
Name:FORBIS, MALIA-ROSE NICOLE (PEER SUPPORT SPEC)
Entity Type:Individual
Prefix:MISS
First Name:MALIA-ROSE
Middle Name:NICOLE
Last Name:FORBIS
Suffix:
Gender:F
Credentials:PEER SUPPORT SPEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 KNOX ST N APT 1
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-1400
Mailing Address - Country:US
Mailing Address - Phone:503-899-5660
Mailing Address - Fax:
Practice Address - Street 1:3878 BEVERLY AVE NE BLDG H
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1394
Practice Address - Country:US
Practice Address - Phone:503-576-4584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA4730171M00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator