Provider Demographics
NPI:1215602768
Name:FORTT, AVALON YASMINE
Entity type:Individual
Prefix:
First Name:AVALON
Middle Name:YASMINE
Last Name:FORTT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 TOWBIN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5928
Mailing Address - Country:US
Mailing Address - Phone:833-599-2560
Mailing Address - Fax:
Practice Address - Street 1:850 TOWBIN AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5928
Practice Address - Country:US
Practice Address - Phone:833-599-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician