Provider Demographics
NPI:1568489128
Name:SEYMOUR, FORREST WILSON (LICSW)
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:WILSON
Last Name:SEYMOUR
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 DOUGLASS ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-3227
Mailing Address - Country:US
Mailing Address - Phone:603-721-9979
Mailing Address - Fax:603-721-9979
Practice Address - Street 1:103 ROXBURY ST
Practice Address - Street 2:SUITE 207
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-8801
Practice Address - Country:US
Practice Address - Phone:603-721-9979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHLICSW 13181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical