Provider Demographics
NPI:1720280613
Name:FORSYTH, CHARLENE JEAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:JEAN
Last Name:FORSYTH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:110 2ND ST S
Mailing Address - Street 2:STE #301
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-1314
Mailing Address - Country:US
Mailing Address - Phone:320-252-2976
Mailing Address - Fax:320-656-1570
Practice Address - Street 1:110 2ND ST S
Practice Address - Street 2:STE #301
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1314
Practice Address - Country:US
Practice Address - Phone:320-252-2976
Practice Address - Fax:320-656-1570
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-03
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN4788103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral