Basic Information
| Provider Information | |||||||||
| NPI: | 1952776403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORSYTH | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | AMFT 128339 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4910 E ASHLAN AVE # SUT118 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937263020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592560100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1925 E DAKOTA AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937264821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595456994 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2015 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF88791 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 128339 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.