Provider Demographics
NPI:1508227646
Name:FORAKER, GERALDINE
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:FORAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:HUNG NGOH
Other - Middle Name:
Other - Last Name:FORAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1548 E PINEY RD
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-3849
Mailing Address - Country:US
Mailing Address - Phone:615-446-9410
Mailing Address - Fax:
Practice Address - Street 1:402 CENTER AVE
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2458
Practice Address - Country:US
Practice Address - Phone:615-446-2134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN63701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508075Medicaid