Provider Demographics
NPI:1104425172
Name:KOSTEK, FORREST BLAKE
Entity type:Individual
Prefix:
First Name:FORREST
Middle Name:BLAKE
Last Name:KOSTEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 E SWANSON AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7004
Mailing Address - Country:US
Mailing Address - Phone:907-715-9423
Mailing Address - Fax:
Practice Address - Street 1:291 E SWANSON AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7004
Practice Address - Country:US
Practice Address - Phone:907-715-9423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health