Provider Demographics
NPI:1194842062
Name:FORMAN, LESLIE I (PHD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:I
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:PO BOX 1039
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-1000
Mailing Address - Country:US
Mailing Address - Phone:626-280-6510
Mailing Address - Fax:
Practice Address - Street 1:7600 GRAVES AVE
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-3414
Practice Address - Country:US
Practice Address - Phone:626-280-6510
Practice Address - Fax:626-288-1026
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10879103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical