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Provider Information for 1730957614


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CRYSTAL FORGET LCSW, LAC


Sex: Female

NPI: 1730957614
Last Updated: 2024-05-30
Certification Date: 2024-05-30

Details

NameValue
NPI1730957614
Enumeration Date2023-12-19
NPI TypeNPI-1 Individual
Sole ProprietorNO
StatusActive
Mailing Address 87 W OLD BROADMOOR RD
COLORADO SPRINGS, CO 80906-3332
United States

Phone: 845-551-1140 | Fax:
 
Primary Practice Address 87 W OLD BROADMOOR RD
COLORADO SPRINGS, CO 80906-3332
United States

Phone: 845-551-1140 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 101YA0400X - Counselor - Addiction (Substance Use Disorder)COACD.0002288
Yes 1041C0700X - Social Worker - ClinicalCOCSW.09930354