Basic Information
| Provider Information | |||||||||
| NPI: | 1265564330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLSTROM | ||||||||
| FirstName: | FOREST | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 MOORPARK WAY APT 304 | ||||||||
| Address2: | |||||||||
| City: | TOLUCA LAKE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916022472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106864656 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 WILSHIRE BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134817464 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW 25536 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | ASW24979 | CA | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.