Provider Demographics
NPI:1679227615
Name:ANDERSON, FORREST
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:
Last Name:ANDERSON
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 1:1712 DEARBORN ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5039
Mailing Address - Country:US
Mailing Address - Phone:253-720-5888
Mailing Address - Fax:
Practice Address - Street 1:3307 CALDWELL BLVD STE 104
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-6403
Practice Address - Country:US
Practice Address - Phone:208-465-4833
Practice Address - Fax:208-467-2654
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8558101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health