Healthcare Provider Details

I. General information

NPI: 1831873801
Provider Name (Legal Business Name): FOREST ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8439 STATE ROAD 26 E
LAFAYETTE IN
47905-9519
US

IV. Provider business mailing address

44 JESTER CT
LAFAYETTE IN
47905-7608
US

V. Phone/Fax

Practice location:
  • Phone: 765-414-0125
  • Fax:
Mailing address:
  • Phone: 765-414-0125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GRETCHEN SHISSLER
Title or Position: EXECUTIVE DIRECTOR
Credential: MOTR/L
Phone: 765-414-0125