Provider Demographics
NPI:1740681055
Name:FORREST, CONSTANCE R (PSYD)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:R
Last Name:FORREST
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 449
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4743
Mailing Address - Country:US
Mailing Address - Phone:310-305-7918
Mailing Address - Fax:
Practice Address - Street 1:2730 WILSHIRE BLVD
Practice Address - Street 2:SUITE 449
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4743
Practice Address - Country:US
Practice Address - Phone:310-305-7918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-06
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 14549103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical