Provider Demographics
NPI:1194359919
Name:BAER FORMAN, MARYANN (SLP)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:BAER FORMAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1857 KNOLL DRIVE
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003
Mailing Address - Country:US
Mailing Address - Phone:805-667-8200
Mailing Address - Fax:805-667-8001
Practice Address - Street 1:1857 KNOLL DRIVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003
Practice Address - Country:US
Practice Address - Phone:805-667-8200
Practice Address - Fax:805-667-8001
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4450235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist