Healthcare Provider Details

I. General information

NPI: 1114291234
Provider Name (Legal Business Name): KAISER PERMANENTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 SUMMIT AVENUE
KENSINGTON MD
20895
US

IV. Provider business mailing address

10500 SUMMIT AVENUE
KENSINGTON MD
20895
US

V. Phone/Fax

Practice location:
  • Phone: 301-897-2500
  • Fax:
Mailing address:
  • Phone: 301-897-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number13240
License Number StateMD

VIII. Authorized Official

Name: BARRY LEE FORREST
Title or Position: PSYCHOTHERAPIST II
Credential: LCSW-C
Phone: 240-620-1399