Provider Demographics
NPI:1912650722
Name:FORSYTHE, JOSHUA (CPRC CPRM)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:FORSYTHE
Suffix:
Gender:M
Credentials:CPRC CPRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 W MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2943
Mailing Address - Country:US
Mailing Address - Phone:313-344-9099
Mailing Address - Fax:
Practice Address - Street 1:1660 OAKMAN BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-2791
Practice Address - Country:US
Practice Address - Phone:313-924-8284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
324500000X
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1912650722Medicaid