Provider Demographics
NPI:1972124584
Name:FORREST, KATHLEEN CLEARY
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CLEARY
Last Name:FORREST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 MCDANIEL ST SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-3655
Mailing Address - Country:US
Mailing Address - Phone:847-271-8155
Mailing Address - Fax:
Practice Address - Street 1:1820 THE EXCHANGE SE STE 750
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-2088
Practice Address - Country:US
Practice Address - Phone:828-668-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW009092104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW009092OtherPROFESSIONAL LICENSE