Provider Demographics
NPI:1912219775
Name:FORTH, STEVEN MICHAEL (BCABA)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:MICHAEL
Last Name:FORTH
Suffix:
Gender:M
Credentials:BCABA
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 3484
Mailing Address - Street 2:
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019-3484
Mailing Address - Country:US
Mailing Address - Phone:650-484-6240
Mailing Address - Fax:
Practice Address - Street 1:12150 SAN MATEO RD
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-7108
Practice Address - Country:US
Practice Address - Phone:650-484-6240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0-05-1774103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst