Provider Demographics
NPI:1063915098
Name:FORSYTH, ALICE KATHERINE (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:KATHERINE
Last Name:FORSYTH
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 GREENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2882
Mailing Address - Country:US
Mailing Address - Phone:973-743-5219
Mailing Address - Fax:
Practice Address - Street 1:73 PARK ST FL 2
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2903
Practice Address - Country:US
Practice Address - Phone:973-255-8206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC056784001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0450239034Medicaid