Provider Demographics
NPI:1457148512
Name:FORSTROM, MARK A SR
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:FORSTROM
Suffix:SR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 BISHOP RD SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1534 BISHOP RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7354
Practice Address - Country:US
Practice Address - Phone:360-357-2370
Practice Address - Fax:360-357-2374
Is Sole Proprietor?:No
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool