Provider Demographics
NPI:1265564330
Name:COLSTROM, FOREST (LCSW)
Entity type:Individual
Prefix:MR
First Name:FOREST
Middle Name:
Last Name:COLSTROM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 MOORPARK WAY APT 304
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2472
Mailing Address - Country:US
Mailing Address - Phone:310-686-4656
Mailing Address - Fax:
Practice Address - Street 1:1200 WILSHIRE BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1908
Practice Address - Country:US
Practice Address - Phone:213-481-7464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 255361041C0700X
CAASW24979104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker