1972124584 NPI number — KATHLEEN CLEARY FORREST

Table of content: KATHLEEN CLEARY FORREST (NPI 1972124584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972124584 NPI number — KATHLEEN CLEARY FORREST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORREST
Provider First Name:
KATHLEEN
Provider Middle Name:
CLEARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972124584
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1165 MCDANIEL ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30310-3655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-271-8155
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1820 THE EXCHANGE SE STE 750
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30339-2088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-668-2180
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  CSW009092 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CSW009092 . This is a "PROFESSIONAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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