Provider Demographics
NPI:1518183862
Name:FORREST, BONNY J (JD, PHD)
Entity Type:Individual
Prefix:DR
First Name:BONNY
Middle Name:J
Last Name:FORREST
Suffix:
Gender:F
Credentials:JD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 4TH AVE
Mailing Address - Street 2:SUITE 609
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6967
Mailing Address - Country:US
Mailing Address - Phone:917-687-0271
Mailing Address - Fax:
Practice Address - Street 1:311 4TH AVE
Practice Address - Street 2:SUITE 609
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6967
Practice Address - Country:US
Practice Address - Phone:917-687-0271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC353103G00000X, 103TB0200X, 103TC2200X, 103TF0200X, 103TM1800X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy