Provider Demographics
NPI:1427197177
Name:FORSTROM, CONNIE R (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:R
Last Name:FORSTROM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BROOKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-2300
Mailing Address - Country:US
Mailing Address - Phone:775-340-1878
Mailing Address - Fax:
Practice Address - Street 1:850 ELM ST
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-3349
Practice Address - Country:US
Practice Address - Phone:775-753-8646
Practice Address - Fax:775-777-1195
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2011-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-1184235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG 4815Medicaid