Provider Demographics
NPI:1235265638
Name:FORSMAN, TANYA R (MC)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:R
Last Name:FORSMAN
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 SOUTH 5TH AVE
Mailing Address - Street 2:SUITE 155
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-232-2506
Mailing Address - Fax:208-478-9558
Practice Address - Street 1:275 SOUTH 5TH AVE
Practice Address - Street 2:SUITE 155
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-2506
Practice Address - Fax:208-478-9558
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health