Provider Demographics
NPI:1649086778
Name:FORSTROM, MARK (LMHC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FORSTROM
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6704 STONYBROOK LN NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5942
Mailing Address - Country:US
Mailing Address - Phone:319-270-2880
Mailing Address - Fax:
Practice Address - Street 1:1642 42ND ST NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-3076
Practice Address - Country:US
Practice Address - Phone:319-377-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA105658101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health