Provider Demographics
NPI:1417007899
Name:PHILLIPS, FORMAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:FORMAN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 W SAND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WYNANTSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12198-7954
Mailing Address - Country:US
Mailing Address - Phone:518-283-1974
Mailing Address - Fax:518-283-2018
Practice Address - Street 1:9 W SAND LAKE RD
Practice Address - Street 2:
Practice Address - City:WYNANTSKILL
Practice Address - State:NY
Practice Address - Zip Code:12198-7954
Practice Address - Country:US
Practice Address - Phone:518-283-1974
Practice Address - Fax:518-283-2018
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4809103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01653194Medicaid
NY51475BMedicare ID - Type Unspecified