Provider Demographics
NPI:1184183477
Name:FORREST, ANGILENE NICHOLE
Entity Type:Individual
Prefix:
First Name:ANGILENE
Middle Name:NICHOLE
Last Name:FORREST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 MOORE RD
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-6735
Mailing Address - Country:US
Mailing Address - Phone:209-735-2244
Mailing Address - Fax:
Practice Address - Street 1:1768 MITCHELL RD STE 301
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-2156
Practice Address - Country:US
Practice Address - Phone:209-353-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)