Provider Demographics
NPI:1225639990
Name:MINDY E FORMAN PSYD LLC
Entity Type:Organization
Organization Name:MINDY E FORMAN PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGISY
Authorized Official - Prefix:DR
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:ERIN
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:248-703-4880
Mailing Address - Street 1:255 BRISTOL CT
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4850
Mailing Address - Country:US
Mailing Address - Phone:248-703-4880
Mailing Address - Fax:
Practice Address - Street 1:1020 MILWAUKEE AVE STE 110
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-3555
Practice Address - Country:US
Practice Address - Phone:248-703-4880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE