Provider Demographics
NPI:1922362268
Name:FORREST, SOPHIA L (CARR)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:L
Last Name:FORREST
Suffix:
Gender:F
Credentials:CARR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14435 HAMLIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-6205
Mailing Address - Country:US
Mailing Address - Phone:818-997-1930
Mailing Address - Fax:818-997-1905
Practice Address - Street 1:14435 HAMLIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-6205
Practice Address - Country:US
Practice Address - Phone:818-997-1930
Practice Address - Fax:818-997-1905
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12365101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)