Provider Demographics
NPI:1518039437
Name:FORT, RICHARD EDWARD (MFT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:EDWARD
Last Name:FORT
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 W LANGSTON ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3123
Mailing Address - Country:US
Mailing Address - Phone:909-982-8687
Mailing Address - Fax:
Practice Address - Street 1:1020 W 8TH ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6326
Practice Address - Country:US
Practice Address - Phone:909-982-2638
Practice Address - Fax:909-931-9931
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT013902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist