Provider Demographics
NPI:1861484172
Name:FORMAN, NANCY WALKER (PHD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:WALKER
Last Name:FORMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3545 OLENTANGY RIVER RD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3907
Mailing Address - Country:US
Mailing Address - Phone:614-263-5908
Mailing Address - Fax:614-263-5941
Practice Address - Street 1:3545 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 214
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3907
Practice Address - Country:US
Practice Address - Phone:614-263-5908
Practice Address - Fax:614-263-5941
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4417103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP24331Medicare PIN