Provider Demographics
NPI:1174940878
Name:FORSYTH, MOLLY (LAC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:FORSYTH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 PARK AVE
Mailing Address - Street 2:APT 4B
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-4420
Mailing Address - Country:US
Mailing Address - Phone:646-734-5175
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY
Practice Address - Street 2:SUITE 1001
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6008
Practice Address - Country:US
Practice Address - Phone:646-480-2542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25005244171100000X
NJ25MZ00105500171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist