Provider Demographics
NPI:1124238415
Name:FORESTA, DOUGLAS (LICSW)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:FORESTA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 WALNUT ST
Mailing Address - Street 2:#2R
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01020-1857
Mailing Address - Country:US
Mailing Address - Phone:413-883-5518
Mailing Address - Fax:
Practice Address - Street 1:71 MARY ST
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-1139
Practice Address - Country:US
Practice Address - Phone:413-737-9544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1166901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical