Provider Demographics
NPI:1558961227
Name:FORESTER, MARK DAVID (BS CCSH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:FORESTER
Suffix:
Gender:M
Credentials:BS CCSH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1822 N SYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-2755
Mailing Address - Country:US
Mailing Address - Phone:817-379-6334
Mailing Address - Fax:817-379-6335
Practice Address - Street 1:1822 N SYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-2755
Practice Address - Country:US
Practice Address - Phone:817-379-6334
Practice Address - Fax:817-379-6335
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1081246Z00000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty