Provider Demographics
NPI:1043893720
Name:FORMAN, PAULA MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:MICHELLE
Last Name:FORMAN
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 1:6910 S HIGHLAND DR REAR
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3001
Mailing Address - Country:US
Mailing Address - Phone:801-935-4171
Mailing Address - Fax:801-935-4946
Practice Address - Street 1:6910 S HIGHLAND DR REAR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-3001
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:801-935-4946
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5874OtherHEALTH PROVIDER
UT238Medicaid
UT568946544OtherBCBS