Provider Demographics
NPI:1447657036
Name:FORT, DENISE C (PHD)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:C
Last Name:FORT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 114TH AVE SE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-6942
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 114TH AVE SE
Practice Address - Street 2:SUITE 210
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-6942
Practice Address - Country:US
Practice Address - Phone:202-747-4085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60477451102L00000X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent