Provider Demographics
NPI:1164868030
Name:FORMAN, MARY SCHULTZ (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SCHULTZ
Last Name:FORMAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:S
Other - Last Name:FORMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:661 EAST ST
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-3721
Mailing Address - Country:US
Mailing Address - Phone:860-733-2828
Mailing Address - Fax:
Practice Address - Street 1:415 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4296
Practice Address - Country:US
Practice Address - Phone:203-931-1184
Practice Address - Fax:203-931-0063
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004082364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health