Provider Demographics
NPI:1265651335
Name:FORMAN, LISA MICHELE (MS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELE
Last Name:FORMAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 LISA AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-5016
Mailing Address - Country:US
Mailing Address - Phone:508-747-8137
Mailing Address - Fax:
Practice Address - Street 1:206 BREEDS HILL RD
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-1881
Practice Address - Country:US
Practice Address - Phone:508-775-0275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health