Provider Demographics
NPI:1346322674
Name:FORMAN, LAURA G (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:G
Last Name:FORMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:G
Other - Last Name:ROBERTO-FORMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:327 W 21ST ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-2130
Mailing Address - Country:US
Mailing Address - Phone:757-622-9852
Mailing Address - Fax:757-622-4033
Practice Address - Street 1:327 W 21ST ST
Practice Address - Street 2:SUITE 205
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-2130
Practice Address - Country:US
Practice Address - Phone:757-622-9852
Practice Address - Fax:757-622-4033
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001083103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007734301Medicaid
VA009814T23Medicare ID - Type Unspecified