Provider Demographics
NPI:1437927894
Name:FORNESS, KIP MICHAEL
Entity Type:Individual
Prefix:
First Name:KIP
Middle Name:MICHAEL
Last Name:FORNESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 MAIN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:AMESBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01913-3766
Mailing Address - Country:US
Mailing Address - Phone:616-914-5466
Mailing Address - Fax:
Practice Address - Street 1:167 MAIN ST APT 2
Practice Address - Street 2:
Practice Address - City:AMESBURY
Practice Address - State:MA
Practice Address - Zip Code:01913-3766
Practice Address - Country:US
Practice Address - Phone:616-914-5466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist