Healthcare Provider Details

I. General information

NPI: 1457007130
Provider Name (Legal Business Name): ALYSSA M FORST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 02/22/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 U.S. HIGHWAY 441, SUITE B3
FRUITLAND PARK FL
34731-4497
US

IV. Provider business mailing address

3261 U.S. HIGHWAY 441, SUITE B3
FRUITLAND PARK FL
34731-4497
US

V. Phone/Fax

Practice location:
  • Phone: 352-323-0612
  • Fax:
Mailing address:
  • Phone: 352-323-0612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: