Provider Demographics
NPI:1376307918
Name:FORTE, BLAIR CRISTIN
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:CRISTIN
Last Name:FORTE
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 1:4109 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-4600
Mailing Address - Country:US
Mailing Address - Phone:631-503-1539
Mailing Address - Fax:
Practice Address - Street 1:4109 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-4600
Practice Address - Country:US
Practice Address - Phone:631-503-1539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY06-P127066-01106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist