Provider Demographics
NPI:1851768725
Name:FORMAN, MINDY (PSYD)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:FORMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1248 AMERICAN WAY
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3936
Mailing Address - Country:US
Mailing Address - Phone:224-433-6744
Mailing Address - Fax:
Practice Address - Street 1:1248 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3936
Practice Address - Country:US
Practice Address - Phone:224-433-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL071.009917103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1851768725Medicaid