Provider Demographics
NPI:1710493416
Name:FORMAN, MOZELLE
Entity Type:Individual
Prefix:
First Name:MOZELLE
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 1:1172 ELBERON AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-4506
Mailing Address - Country:US
Mailing Address - Phone:732-668-2187
Mailing Address - Fax:
Practice Address - Street 1:1138 E 9TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-4704
Practice Address - Country:US
Practice Address - Phone:732-668-2187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NY0539891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical