Provider Demographics
NPI:1942746987
Name:FOURMAN, ALICE (LPC, LSW)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:FOURMAN
Suffix:
Gender:F
Credentials:LPC, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4464 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-5464
Mailing Address - Country:US
Mailing Address - Phone:513-649-8008
Mailing Address - Fax:513-649-8004
Practice Address - Street 1:4464 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45005-5464
Practice Address - Country:US
Practice Address - Phone:513-649-8008
Practice Address - Fax:513-649-8004
Is Sole Proprietor?:No
Enumeration Date:2017-01-15
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0013062104100000X, 104100000X
OHC.0002170-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0074861OtherMEDICAID-ODADAS
OH0074946OtherMEDICAID-ODMH
OHH130910OtherMEDICARE GROUP PTAN
OH01-0693OtherCARF CERTIFICATION