Provider Demographics
NPI:1023323110
Name:FORREST, PHILIP EAN
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:EAN
Last Name:FORREST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 S GLOBE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-7374
Mailing Address - Country:US
Mailing Address - Phone:575-693-1140
Mailing Address - Fax:
Practice Address - Street 1:220 W 2ND ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6232
Practice Address - Country:US
Practice Address - Phone:575-356-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor