Healthcare Provider Details

I. General information

NPI: 1922163674
Provider Name (Legal Business Name): RICHARD PAUL FORLEO LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 DANIEL WEBSTER HWY
MERRIMACK NH
03054-3407
US

IV. Provider business mailing address

5 DAVIDSON AVE
MERRIMACK NH
03054-3841
US

V. Phone/Fax

Practice location:
  • Phone: 603-429-1190
  • Fax:
Mailing address:
  • Phone: 603-424-8583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number754
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number105697
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier30420303
Identifier TypeMEDICAID
Identifier StateMH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: