Healthcare Provider Details

I. General information

NPI: 1124376298
Provider Name (Legal Business Name): MALIA-ROSE NICOLE FORBIS PEER SUPPORT SPEC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 03/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3878 BEVERLY AVE NE BLDG H
SALEM OR
97305-1394
US

IV. Provider business mailing address

379 KNOX ST N APT 1
MONMOUTH OR
97361-1400
US

V. Phone/Fax

Practice location:
  • Phone: 503-576-4584
  • Fax:
Mailing address:
  • Phone: 503-899-5660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberA4730
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: