Provider Demographics
NPI:1376288571
Name:LAURA G FORMAN, PSY.D, FAPA, LLC
Entity Type:Organization
Organization Name:LAURA G FORMAN, PSY.D, FAPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:G
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:757-550-1735
Mailing Address - Street 1:129 W VIRGINIA BEACH BLVD # 204B
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-2030
Mailing Address - Country:US
Mailing Address - Phone:757-550-1735
Mailing Address - Fax:757-622-4033
Practice Address - Street 1:129 W VIRGINIA BEACH BLVD # 204B
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-2030
Practice Address - Country:US
Practice Address - Phone:757-550-1735
Practice Address - Fax:757-622-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty