Provider Demographics
NPI:1164837340
Name:FORZLEY, SHERRY R (BCBA)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:R
Last Name:FORZLEY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 MIAMI ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-1336
Mailing Address - Country:US
Mailing Address - Phone:574-234-9282
Mailing Address - Fax:
Practice Address - Street 1:912 MIDDLEBURY ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-2739
Practice Address - Country:US
Practice Address - Phone:574-383-0107
Practice Address - Fax:877-804-8654
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-16-21690103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0-14-5982OtherBEHAVIOR ANALYSIS CERTIFICATION BOARD