Provider Demographics
NPI:1164783023
Name:FORESTA, ELIZABETH (MSED)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:FORESTA
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 MASSAPEQUA AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5221
Mailing Address - Country:US
Mailing Address - Phone:631-807-5042
Mailing Address - Fax:
Practice Address - Street 1:401 MASSAPEQUA AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5221
Practice Address - Country:US
Practice Address - Phone:631-807-5042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY871488174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist