Provider Demographics
NPI:1750384103
Name:FORMAN LEBOEUF, MARYELIZABETH (PHD)
Entity type:Individual
Prefix:DR
First Name:MARYELIZABETH
Middle Name:
Last Name:FORMAN LEBOEUF
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARYELIZABETH
Other - Middle Name:
Other - Last Name:FORMAN LEBOEUF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1651 THIBODEAUX AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-8271
Mailing Address - Country:US
Mailing Address - Phone:225-267-7763
Mailing Address - Fax:855-398-6697
Practice Address - Street 1:1651 THIBODEAUX AVE STE A
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-8271
Practice Address - Country:US
Practice Address - Phone:225-267-7763
Practice Address - Fax:855-398-6697
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2024-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA975103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2128850Medicaid
LA2128850Medicaid
LA3B971DX80Medicare PIN