Healthcare Provider Details

I. General information

NPI: 1265564330
Provider Name (Legal Business Name): FOREST COLSTROM LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 WILSHIRE BLVD SUITE 210
LOS ANGELES CA
90017-1908
US

IV. Provider business mailing address

4401 MOORPARK WAY APT 304
TOLUCA LAKE CA
91602-2472
US

V. Phone/Fax

Practice location:
  • Phone: 213-481-7464
  • Fax:
Mailing address:
  • Phone: 310-686-4656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW24979
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 25536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: