Provider Demographics
NPI:1982041364
Name:FORMAN, REBEKAH (PHD)
Entity Type:Individual
Prefix:DR
First Name:REBEKAH
Middle Name:
Last Name:FORMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3126 W CARY ST # 404
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-3504
Mailing Address - Country:US
Mailing Address - Phone:804-554-1760
Mailing Address - Fax:
Practice Address - Street 1:1300 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5054
Practice Address - Country:US
Practice Address - Phone:804-828-4231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005256103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAZLF120196911OtherREGENCE BLUE SHIELD ID NUMBER