Provider Demographics
NPI:1699025080
Name:FORNWALT, JOANNA
Entity Type:Individual
Prefix:MRS
First Name:JOANNA
Middle Name:
Last Name:FORNWALT
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 1:130 MAPLE ST
Mailing Address - Street 2:SUITE 325
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-2202
Mailing Address - Country:US
Mailing Address - Phone:413-737-9544
Mailing Address - Fax:
Practice Address - Street 1:130 MAPLE ST
Practice Address - Street 2:SUITE 325
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2202
Practice Address - Country:US
Practice Address - Phone:413-737-9544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical