Provider Demographics
NPI:1568895480
Name:FORMAN, KELLY ANN (LSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:FORMAN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:OH
Mailing Address - Zip Code:43074-0073
Mailing Address - Country:US
Mailing Address - Phone:614-407-4033
Mailing Address - Fax:
Practice Address - Street 1:691 N HIGH ST
Practice Address - Street 2:SUITE 303
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1583
Practice Address - Country:US
Practice Address - Phone:614-407-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.12004171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical