Provider Demographics
NPI:1942416870
Name:FORSMAN, KATHLEEN MARY (QMRP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARY
Last Name:FORSMAN
Suffix:
Gender:F
Credentials:QMRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 W 440 S
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-8968
Mailing Address - Country:US
Mailing Address - Phone:435-789-7077
Mailing Address - Fax:435-789-7077
Practice Address - Street 1:3355 W 440 S
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-8968
Practice Address - Country:US
Practice Address - Phone:435-789-7077
Practice Address - Fax:435-789-7077
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6267566-0160OtherENTITY NUMBER
UT6267566-0160OtherENTITY NUMBER