Provider Demographics
NPI:1962508291
Name:FORMAN, LAURIE M (MS SOCIAL WORK)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:M
Last Name:FORMAN
Suffix:
Gender:M
Credentials:MS SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 MERRICK RD
Mailing Address - Street 2:STE 205
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710
Mailing Address - Country:US
Mailing Address - Phone:516-679-6673
Mailing Address - Fax:516-679-6673
Practice Address - Street 1:2631 MERRICK RD
Practice Address - Street 2:STE 205
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710
Practice Address - Country:US
Practice Address - Phone:516-679-6673
Practice Address - Fax:516-679-6673
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR03173711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244817Medicaid
W02541Medicare ID - Type Unspecified