Provider Demographics
NPI:1326558297
Name:FORMAN PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:FORMAN PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:804-554-1760
Mailing Address - Street 1:2800 N PARHAM RD STE 107
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-4409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 N PARHAM RD STE 107
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4409
Practice Address - Country:US
Practice Address - Phone:804-554-1760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005256261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)