Provider Demographics
NPI:1407323512
Name:FORMA, DANIELLE LAUREN
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:LAUREN
Last Name:FORMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 TOPAZ LN
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3211
Mailing Address - Country:US
Mailing Address - Phone:032-610-0754
Mailing Address - Fax:
Practice Address - Street 1:19 TOPAZ LN
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3211
Practice Address - Country:US
Practice Address - Phone:203-610-0754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-26
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT4881101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program