Provider Demographics
NPI:1619021060
Name:FORKENBROCK, CHRISTY ALLISON (MA RAS)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTY
Middle Name:ALLISON
Last Name:FORKENBROCK
Suffix:
Gender:F
Credentials:MA RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3862
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-3862
Mailing Address - Country:US
Mailing Address - Phone:760-647-6236
Mailing Address - Fax:
Practice Address - Street 1:122 MEADOW LANE
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546
Practice Address - Country:US
Practice Address - Phone:760-647-6236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF0401230924101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)