Provider Demographics
NPI:1457050007
Name:FORTENBERRY, GARY (LMFT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:FORTENBERRY
Suffix:
Gender:M
Credentials:LMFT
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 492551
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-2551
Mailing Address - Country:US
Mailing Address - Phone:530-824-4709
Mailing Address - Fax:
Practice Address - Street 1:715 JACKSON ST STE B
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-3771
Practice Address - Country:US
Practice Address - Phone:530-526-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT35841106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1568903706OtherNPI