Provider Demographics
NPI:1770763823
Name:FORMAN, VERNELL S (MA/CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:VERNELL
Middle Name:S
Last Name:FORMAN
Suffix:
Gender:F
Credentials:MA/CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3294A DOG RIVER RD
Mailing Address - Street 2:
Mailing Address - City:THEODORE
Mailing Address - State:AL
Mailing Address - Zip Code:36582-2524
Mailing Address - Country:US
Mailing Address - Phone:251-443-5154
Mailing Address - Fax:251-661-2579
Practice Address - Street 1:3294A DOG RIVER RD
Practice Address - Street 2:
Practice Address - City:THEODORE
Practice Address - State:AL
Practice Address - Zip Code:36582-2524
Practice Address - Country:US
Practice Address - Phone:251-443-5154
Practice Address - Fax:251-661-2579
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2648235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL00289025OtherSPEECH-LANGUAGE PATHOGIST