Provider Demographics
NPI:1285684456
Name:FORWARD, GORDON M (LCSW)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:M
Last Name:FORWARD
Suffix:
Gender:M
Credentials:LCSW
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 681628
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36068-1628
Mailing Address - Country:US
Mailing Address - Phone:334-875-2100
Mailing Address - Fax:334-418-6540
Practice Address - Street 1:1017 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6780
Practice Address - Country:US
Practice Address - Phone:334-875-2100
Practice Address - Fax:334-418-6540
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL265C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL6273859OtherUBH - BASIC SERVICES
AL6274859OtherUBH - PLUS SERVICES
ALR38290Medicare UPIN