Provider Demographics
NPI:1518601392
Name:FORMAN, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FORMAN
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 1:281 FAWN DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1159
Mailing Address - Country:US
Mailing Address - Phone:415-717-9405
Mailing Address - Fax:
Practice Address - Street 1:166 SANTA CLARA AVE STE 205
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-1323
Practice Address - Country:US
Practice Address - Phone:510-601-1929
Practice Address - Fax:510-660-1194
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0020808101YM0800X
CO0014462106H00000X
390200000X
CA139159106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program