Provider Demographics
NPI:1821590688
Name:FORMAN, MOLLY (RBT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:FORMAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 HARBOR CITY PKWY
Mailing Address - Street 2:D-124
Mailing Address - City:INDIAN HARBOR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937
Mailing Address - Country:US
Mailing Address - Phone:908-917-8906
Mailing Address - Fax:
Practice Address - Street 1:1855 W HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-265-4409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022079000Medicaid