MEDICARE: MR. CARL LEE FORTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	101YM0800X	Mental Health Counselor	NC
2	103K00000X	Behavior Analyst	NC
3	103TC2200X	Clinical Child & Adolescent Psychologist	NC
4	103TE1100X	Exercise & Sports Psychologist	NC
5	103TF0000X	Family Psychologist	NC
6	103TH0100X	Health Service Psychologist	NC
7	103TP2701X	Group Psychotherapy Psychologist	NC
8	106H00000X	Marriage & Family Therapist	NC
9	172A00000X	Driver	NC

General Provider Information

NPI Number	:	1528312733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARL LEE FORTE

Provider Business Mailing Address
First Line	:	5304 DUCKWING DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-6155
Country	:	US
Telephone Number	:	919-376-7006
Fax Number	:

Provider Business Practice Location Address
First Line	:	3211 BRAMER DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-1603
Country	:	US
Telephone Number	:	919-376-7006
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2012
Last Update Date	:	11/09/2012

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