Provider Demographics
NPI:1558892711
Name:FORMAN, BEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BEN
Middle Name:
Last Name:FORMAN
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 1:4843 LANGDRUM LN
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-5412
Mailing Address - Country:US
Mailing Address - Phone:301-986-0626
Mailing Address - Fax:
Practice Address - Street 1:4843 LANGDRUM LN
Practice Address - Street 2:
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-5412
Practice Address - Country:US
Practice Address - Phone:301-986-0626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2249103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical