Healthcare Provider Details

I. General information

NPI: 1184836298
Provider Name (Legal Business Name): MS. MARY-JO FORESTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 REDONDO AVE FL 3
LONG BEACH CA
90806-2325
US

IV. Provider business mailing address

2600 REDONDO AVE FL 3
LONG BEACH CA
90806-2325
US

V. Phone/Fax

Practice location:
  • Phone: 562-256-2900
  • Fax:
Mailing address:
  • Phone: 562-256-2900
  • Fax: 562-256-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number93144
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: