Provider Demographics
NPI:1336742998
Name:FORBES, AMANDA RENEE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:FORBES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEN
Mailing Address - State:LA
Mailing Address - Zip Code:70767-2747
Mailing Address - Country:US
Mailing Address - Phone:225-245-9070
Mailing Address - Fax:225-345-9073
Practice Address - Street 1:415 COURT ST
Practice Address - Street 2:
Practice Address - City:PORT ALLEN
Practice Address - State:LA
Practice Address - Zip Code:70767-2747
Practice Address - Country:US
Practice Address - Phone:225-245-9070
Practice Address - Fax:225-245-9073
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1124567411Medicaid