Provider Demographics
NPI:1952403966
Name:FORMAN, VERNON WAYNE (CERTIFICATIONS)
Entity Type:Individual
Prefix:MR
First Name:VERNON
Middle Name:WAYNE
Last Name:FORMAN
Suffix:
Gender:M
Credentials:CERTIFICATIONS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 S SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2334
Mailing Address - Country:US
Mailing Address - Phone:262-483-0048
Mailing Address - Fax:
Practice Address - Street 1:722 S SPRING ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2334
Practice Address - Country:US
Practice Address - Phone:262-483-0048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1701101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1701OtherCERT. AODA COUNSELOR III
WI11482OtherCERT. CLIN. SUPERVISOR II