Basic Information
| Provider Information | |||||||||
| NPI: | 1255720181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORSTER | ||||||||
| FirstName: | AVIEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 SW OAK ST | ||||||||
| Address2: | STE. 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972041817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039887468 | ||||||||
| FaxNumber: | 5039883015 | ||||||||
| Practice Location | |||||||||
| Address1: | 426 SW STARK ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972042303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039885020 | ||||||||
| FaxNumber: | 5039886899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2015 | ||||||||
| LastUpdateDate: | 01/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | A3185 | OR | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 096511 | 05 | OR | MEDICAID |