Basic Information
| Provider Information | |||||||||
| NPI: | 1487667705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORREST | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | EDWIN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | L.I.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 NORRIS ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021401814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173542697 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 330 BROOKLINE AVE | ||||||||
| Address2: | BETH ISRAEL DEACONESS MEDICAL CENTER/EAST | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176677000 | ||||||||
| FaxNumber: | 6176678665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 104100000X | 110768 | MA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.