Provider Demographics
NPI:1629441647
Name:FORRESTER, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FORRESTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 ELENA ST
Mailing Address - Street 2:#1
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1991
Mailing Address - Country:US
Mailing Address - Phone:540-421-1444
Mailing Address - Fax:
Practice Address - Street 1:116 ELENA ST
Practice Address - Street 2:#1
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1991
Practice Address - Country:US
Practice Address - Phone:540-421-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7913225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist