Provider Demographics
NPI:1154094035
Name:FORWARD THERAPEUTIC CENTER
Entity Type:Organization
Organization Name:FORWARD THERAPEUTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HAYWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:332-223-9613
Mailing Address - Street 1:1672 PARK AVE APT 3D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-4653
Mailing Address - Country:US
Mailing Address - Phone:332-223-9613
Mailing Address - Fax:
Practice Address - Street 1:4850 CONNECTICUT AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-5941
Practice Address - Country:US
Practice Address - Phone:332-223-9613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty