Provider Demographics
NPI:1982373486
Name:FORMAN, THOMAS JOSEPH
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:FORMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 THOMPSON LN
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-9040
Mailing Address - Country:US
Mailing Address - Phone:847-245-8346
Mailing Address - Fax:
Practice Address - Street 1:515 THOMPSON LN
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-9040
Practice Address - Country:US
Practice Address - Phone:847-245-8346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1991388103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool