Provider Demographics
NPI:1033218714
Name:FORMAN, ELI MICHAEL SIMONG (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELI
Middle Name:MICHAEL SIMONG
Last Name:FORMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-1219
Mailing Address - Country:US
Mailing Address - Phone:201-592-7388
Mailing Address - Fax:201-592-6301
Practice Address - Street 1:431 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:LEONIA
Practice Address - State:NJ
Practice Address - Zip Code:07605-1219
Practice Address - Country:US
Practice Address - Phone:201-592-7388
Practice Address - Fax:201-592-6301
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5688633101YM0800X
MD0019101YP2500X
MDM038106H00000X
CAMFC13681106H00000X
NJ37F100059900106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist