Provider Demographics
NPI:1124794276
Name:WASHBURN, FORREST LEWIS (OTR/L)
Entity type:Individual
Prefix:
First Name:FORREST
Middle Name:LEWIS
Last Name:WASHBURN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47001 WATERS EDGE LN APT A205
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-3152
Mailing Address - Country:US
Mailing Address - Phone:269-680-1169
Mailing Address - Fax:
Practice Address - Street 1:13331 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-4210
Practice Address - Country:US
Practice Address - Phone:586-788-0702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201011381225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist