Provider Demographics
NPI:1265761258
Name:FORMAN, MELISA (ATR, LPC)
Entity type:Individual
Prefix:MS
First Name:MELISA
Middle Name:
Last Name:FORMAN
Suffix:
Gender:F
Credentials:ATR, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S MAIN ST
Mailing Address - Street 2:SUITE #213
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-4871
Mailing Address - Country:US
Mailing Address - Phone:215-345-8828
Mailing Address - Fax:215-348-3645
Practice Address - Street 1:350 S MAIN ST
Practice Address - Street 2:SUITE #213
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-4871
Practice Address - Country:US
Practice Address - Phone:215-345-8828
Practice Address - Fax:215-348-3645
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-22
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001617101YP2500X
08-011221700000X
PA007920101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist