Provider Demographics
NPI:1790865301
Name:FORMAN, MARJORIE (LCSW LP)
Entity Type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:
Last Name:FORMAN
Suffix:
Gender:F
Credentials:LCSW LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E 39TH ST
Mailing Address - Street 2:SUITE 808
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-0933
Mailing Address - Country:US
Mailing Address - Phone:212-779-0462
Mailing Address - Fax:631-287-6346
Practice Address - Street 1:150 E 39TH ST
Practice Address - Street 2:SUITE 808
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-0933
Practice Address - Country:US
Practice Address - Phone:212-779-0462
Practice Address - Fax:631-287-6346
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0211521041C0700X
NY000232-1102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN14011Medicare ID - Type Unspecified