Provider Demographics
NPI:1235253873
Name:FORMAN, LORINE STACI (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:LORINE
Middle Name:STACI
Last Name:FORMAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:LORINE
Other - Middle Name:STACI
Other - Last Name:BRUCKMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1311 MAMARONECK AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-5224
Mailing Address - Country:US
Mailing Address - Phone:888-830-4125
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:800 DENOW RD STE U
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-5246
Practice Address - Country:US
Practice Address - Phone:609-737-8131
Practice Address - Fax:201-847-0985
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC009978225X00000X
NJ46TR00110900225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist