Provider Demographics
NPI:1952776403
Name:FORSYTH, NICOLE RAE (AMFT 128339)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:RAE
Last Name:FORSYTH
Suffix:
Gender:F
Credentials:AMFT 128339
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1396 W HERNDON AVE # SUT110
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-7126
Mailing Address - Country:US
Mailing Address - Phone:559-256-0100
Mailing Address - Fax:
Practice Address - Street 1:1396 W HERNDON AVE # SUT110
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-7126
Practice Address - Country:US
Practice Address - Phone:559-256-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128339106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700183928Medicaid