Provider Demographics
NPI:1740399369
Name:FORMAN, SHARON (LCSW)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:FORMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 POLHEMUS ST
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-1722
Mailing Address - Country:US
Mailing Address - Phone:845-398-8875
Mailing Address - Fax:
Practice Address - Street 1:11 POLHEMUS ST
Practice Address - Street 2:SUITE 1
Practice Address - City:TAPPAN
Practice Address - State:NY
Practice Address - Zip Code:10983-1722
Practice Address - Country:US
Practice Address - Phone:845-536-8875
Practice Address - Fax:845-398-8875
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0446481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N39Z11Medicare PIN